Elliot Health System- RN Utilization Review- Care Coordination- Full Time

Elliot Hospital; Peterborough (NH); On-site; USD 70,000 - 90,000; Full time

Job summary

Elliot Hospital is seeking a full-time RN Utilization Review professional to oversee hospital services efficiency. The role involves admission reviews, collaboration with payers, and ensuring compliance with hospital guidelines. Candidates must hold a Bachelor's degree in Nursing and have a minimum of three years' experience in case management.

Benefits

Health, dental, prescription, and vision coverage

Short-term and long-term disability insurance

Tuition reimbursement

403(b) Retirement savings plans

Continuous earned time accrual

Qualifications

• Graduate of an accredited nursing program.
• Minimum of three years in hospital case management.
• Active RN license in New Hampshire or Compact State.

Responsibilities

• Complete admission reviews to determine appropriate care level.
• Document continued stay reviews and assess necessity of inpatient care.
• Collaborate with payer care managers to prevent denials.

Skills

Clinical Review

Collaboration

Documentation

Education

Bachelor's degree in Nursing

Job description

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This Position Has Onsite Requirements

About the Role

Under the direction of the Director of Care Coordination, the Utilization Review RN (UR RN) is responsible for ensuring the effective and efficient use of hospital services in line with the hospital's utilization review plan.

Responsibilities

1. Complete admission reviews to determine the appropriate level of care.
2. Document continued stay reviews to assess the necessity of inpatient care, procedures, and estimated length of stay.
3. Collaborate with payer care managers to prevent denials by ensuring timely clinical reviews.
4. Address potential denials proactively, working with physicians and payer representatives to minimize retrospective denials.
5. Screen all patients upon admission or the next business day to determine appropriate level of care using medical necessity tools, Medicare Inpatient Only List, and payer requirements.
6. Monitor observation status patients to ensure appropriate utilization, and collaborate with admitting physicians if documentation does not support the current level of care.
7. Perform concurrent reviews to justify extended stays, working with attending physicians to ensure accurate documentation of medical necessity.
8. Refer cases that do not meet admission or continued stay guidelines to the Utilization Review Physician Advisor after discussions with attending physicians.

Qualifications

• Graduate of an accredited nursing program (Bachelors degree in Nursing required for nurses hired after May 2015 or commitment to obtain within a specified timeframe).
• Minimum of three (3) years of experience in hospital case management or utilization management.
• Active New Hampshire or Compact State RN license required.
• CCM or ACM certification preferred.

Benefits

• Health, dental, prescription, and vision coverage for full-time & part-time employees
• Short-term, long-term disability, life & pet insurance
• Tuition reimbursement
• 403(b) Retirement savings plans
• Continuous earned time accrual

Additional Information

Job Industries: Healthcare

Seniority level: Mid-Senior level

Employment type: Full-time

Job function: Health Care Provider

Industries: Hospitals and Health Care