Lead RN Utilization Review – Inpatient UM

Great River Health Systems; West Burlington (IA); Vor Ort; USD 81.000 - 99.000; Vollzeit

Zusammenfassung

Great River Health Systems in West Burlington, IA, is seeking a Utilization Review Specialist to review clinical documentation in the EMR and certify admissions, ensuring compliance with CMS Conditions of Participation for Utilization Management.

The role leads the Utilization Review Team, coordinates daily huddles, and handles inpatient denials follow-up. Requires RN license, 4–6 years clinical and 1–3 years UM experience; BA/BS Nursing preferred. 8:00am–4:30pm, every 6th weekend 8:00am–8:00pm.

Qualifikationen

• AA nursing required
• 4-6 years clinical experience
• 1-3 years Utilization Review experience
• RN Iowa Board of Nursing (IBON) required
• BA/BS Nursing preferred

Aufgaben

• Review inpatient encounters for medical necessity.
• Gather and analyze clinical documentation to formulate an outcome.
• Make decisions based on facts and evidence; assume responsibility for those decisions.
• Monitor cases for medical necessity/level of care.
• Accurate input of data; manage multiple priorities.
• Lead the Utilization Review team in daily tasks and huddles.
• Submit appeals of denied claims and follow up until resolution.

Kenntnisse

Excellent communication skills

Ausbildung

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing (BA/BS) preferred

Jobbeschreibung

Great River Health Systems in West Burlington, IA, is seeking a Utilization Review Specialist to review clinical documentation in the EMR and certify admissions, ensuring compliance with CMS Conditions of Participation for Utilization Management.

The role leads the Utilization Review Team, coordinates daily huddles, and handles inpatient denials follow-up. Requires RN license, 4–6 years clinical and 1–3 years UM experience; BA/BS Nursing preferred. 8:00am–4:30pm, every 6th weekend 8:00am–8:00pm.