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Manage patient progression of care, promote evidence-based protocols, and ensure appropriateness of interventions to expedite care delivery.
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Direct patient care services to ensure timely and appropriate patient discharge.
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Perform continuing review of patient hospitalizations to monitor medical necessity, appropriateness of care, length of stay, and quality of services.
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Conduct utilization management and review functions for patients admitted to the facility and those referred to other facilities via Purchased/Referred Care Services.
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Obtain and review necessary medical reports and treatment plans as requested by regulatory agencies or payers.
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Review and validate physician orders, report patient progress, and document unusual occurrences.
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Collaborate with leadership, clinical care teams, and physicians to ensure healthcare services are appropriate and cost-effective, adhering to UM/CM/DCP plans.
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Assess new hospital admissions to determine patient conditions and needs for personalized treatment plan development.
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Provide patients and/or their families with information regarding healthcare benefits.
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Participate in interdisciplinary collaboration with professional staff and review patient records.
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Ensure maintenance of the Utilization Review Plan in collaboration with the Utilization Review Medical Director or designated provider.
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Facilitate educational programs and advise physicians and other departments on regulations affecting UM/CM/DCP.
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Direct the coordination of patient care departments, ensuring treatment plans meet patient needs and comply with hospital, regulatory, and payer criteria.
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Ensure documentation supports UM functions and communicate with payers within required timeframes.
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Review information, communicate results to claims adjusters, and enter appropriate billing information.
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Prepare information for notification letters to providers, staff, and patients.
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Receive and process requests for appeal of denials and respond to complaints per UM review guidelines.
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Maintain utilization review and appeal logs.
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Support clinical improvement initiatives by providing quality review.
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Perform tumor registry functions as required.
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Bachelor’s Degree in Nursing (BSN).
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High School Diploma or equivalent.
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8 years of clinical care or nursing experience, with at least 3 years specifically in chart review, risk management, or related quality service.
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Current Flu vaccine required.
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Proficiency in conducting and reviewing medical records for medical necessity, level of care determination, and public/private insurance reimbursement.
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Basic knowledge of ICD-9 and CPT coding.
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Understanding of regulations set forth by The Centers for Medicare & Medicaid Services (CMS).
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Proficient in medical terminology, anatomy, physiology, and concepts of disease.
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Ability to provide effective nursing care and assess patient situations to take effective courses of action.
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Contract Length: 13 weeks
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Start Date: October 5, 2026
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Call Requirements: Not specified.
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Weekend Rotations: Not specified.
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Note: Start date is contingent upon successful completion of pre-employment fingerprinting and background checks, which may require a processing time of approximately 6 weeks.
