Utilization Review Registered Nurse

Prairie Lakes Healthcare System; Watertown (SD); On-site; USD 58,000 - 93,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Life insurance

403(b) plan

Paid time off

Flexible Spending Account

Employee Assistance Program

Education Loan Program

Community discounts

Job summary

Prairie Lakes Healthcare System in Watertown, SD seeks a full-time Utilization Review Specialist to ensure medical necessity for hospital services and continued stay under Medicare and commercial payors.

This 0.9 status (36 hours per week) on-site role focuses on reviewing admissions within 24 hours, coordinating with physicians, and maintaining accurate documentation and reporting.

Candidates typically have five years of acute health care experience and nursing licensure in South Dakota.

Qualifications

• Five years of acute health care experience.
• Two years experience related to utilization review preferred.

Responsibilities

• Develops and implements effective utilization review functions.
• Reviews inpatient and observation admissions within 24 hours for appropriateness.
• Contacts physicians to justify admission or continued stay.
• Refers cases for action after notifying Discharge Planning/Social Services manager.
• Develops and maintains a system to monitor and review certification completion.
• Maintains complete and accurate documentation reflecting status and denials.
• Reviews and follows through on the appeal process for denials.

Skills

Utilization Review

Admissions review

Physician communication

Medical records

Education

RN license (SD)

Job description

Location: Watertown, SD

Job Id:407

# of Openings:2

Job Summary

Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones

POSITION SUMMARY

Wage: 28.09-44.81

On-site.

This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.

RESPONSIBILITIES

Develops and implements effective utilization review functions resulting in maintaining an average length of stay that is financially justified for hospital operations.

Reviews all inpatient and observation admissions within 24 hours for appropriateness based on approved criteria and standards, Monday through Friday. All weekend admissions are reviewed on the following Monday.

Contacts physicians as required for information to justify admission or continued stay the same day of questionable stay.

Refers all cases where necessity for admission is questionable or potential for denial is identified to the attending physician or his/her designee for appropriate action after notifying the Discharge Planning/Social Services manager.

Develops and maintains a system to monitor and review certification completion.

Maintains complete and accurate documentation which reflects the status of hospital utilization, numbers and categories of cases reviewed, and denials by fiscal intermediaries. Documents and reports back follow-up.

Reviews and follows through the appeal process for patient stay denials.

Other duties may be assigned.

JOB SPECIFICATIONS

Education and/or Experience

Five years of acute health care experience.

Two years experience related to utilization review preferred.

Certificates, Licenses, Registrations

Holds or is eligible for current nursing licensor in the State of South Dakota.

Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance.

Additional benefits for those qualifying include:

• Flexible Spending Account
• Employee Assistance Program for mental health
• Education Loan Program
• Community discounts including the Prairie Lakes Wellness Center

Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.