RN Utilization Review II-Hybrid-FT/Days (8a-430p)

Centra Health; Lynchburg (VA); On-site; USD 40,000 - 63,000; Full time

Job summary

Centra Health in Lynchburg, VA is seeking a Utilization Review Nurse to coordinate admission criteria and ensure regulatory compliance for Medicare, Medicaid, and other payors. The role requires collaboration with physicians, payers, patient access, and clinical teams to optimize patient care and admission processes.

The position requires an accredited nursing degree, 3 years of acute care experience, and Virginia RN (or compact) license with BLS.

Qualifications

• Graduate of an accredited Nursing Program.
• Three (3) years of experience in acute care nursing; strong computer skills and excellent communication.
• Current, active RN license in Virginia or a multistate/compact license; AHA BLS Provider.

Responsibilities

• Provides initial, concurrent and retrospective reviews for severity of illness and intensity of service.
• Interprets InterQual and Milliman & Roberts criteria to ensure admission and continued stay criteria are met.
• Performs admission review on the day after patient admission; details in plan notes.
• Collaborates with Physician Advisor to facilitate utilization management.
• Liaises with patient accounting and access for authorizations and claims.
• Maintains patient confidentiality and complies with federal/state regulations.

Skills

Acute care nursing

Computer skills

Excellent communication

Team collaboration

Education

Nursing degree

RN license (Virginia)

AHA BLS Provider

Tools

InterQual criteria

Milliman & Roberts criteria

Job description

Job Description Utilization review nurse is responsible for the day to day coordination of admission criteria as it relates to healthcare needs of the patient and organization. Including knowledge of regulatory and compliance with Medicare, Medicaid and other insurance payors. This team member will communicate with a variety of clinical discipline, commercial payers, patient access, patient financial services, physician advisor and other staff members.

Job Description Utilization review nurse is responsible for the day to day coordination of admission criteria as it relates to healthcare needs of the patient and organization. Including knowledge of regulatory and compliance with Medicare, Medicaid and other insurance payors. This team member will communicate with a variety of clinical discipline, commercial payers, patient access, patient financial services, physician advisor and other staff members.

Responsibilities

• Provides, initial, concurrent and retrospective reviews if assigned patients for severity of illness and intensity of service
• Demonstrates the ability to interpret InterQual and Milliman and Roberts criteria to ensure the patients meet admission and continued stay criteria
• Provides accurate and complete account authorization and details in plan notes
• Performs admission review on the following business day of patient's admission
• Involves the Physician Advisor as needed when physician-to-physician interaction is required to achieve appropriate clinical utilization for the patient
• Collaboratively works with the Physician Advisor to facilitate all aspects of the utilization management plan
• Serve as a liaison to patient accounting, patients access as it relates to authorizations and claims
• Demonstrates ability to communicate effectively with internal and external customers
• Demonstrates commitment toward customer satisfaction and patient advocacy
• Maintains confidentiality of patient/physician/and other team members as well as maintaining compliance with all federal/state guidelines and regulations
• Achieves budget length of stay (LOS) goal
• May perform other duties as assigned or requested and job specification can be modified or updated at any time

Qualifications

Required Education: Graduate of an accredited Nursing Program.

Required Experience / Skills: Three (3) years of experience in acute care nursing. Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines

Required Certifications and Licensures: Hold a current, active license as a registered nurse in Virginia or hold a current multistate/compact license. AHA BLS Provider.

Salary Range: $29.29-$45.41/hr.