Utilization Review RN - Per Diem*

Carson Valley Heath; Gardnerville (NV); On-site; USD 83,000 - 103,000; Part time

Job summary

Carson Valley Health in Nevada is seeking a Utilization Review RN for per diem coverage. The role focuses on chart reviews to ensure InterQual-based criteria are met, coordinating with payors and hospital departments to maximize reimbursement and support medical necessity documentation.

The position requires Nevada RN licensure, 1 year of case management or utilization management experience, and familiarity with InterQual or McKesson criteria. Per diem terms include an enhanced hourly rate.

Qualifications

• RN with active Nevada license and in good standing; 1 year of case management or utilization management experience preferred.
• Bachelor's degree in nursing preferred; 3+ years clinical care or nursing experience or equivalent combination with 2 years Utilization Review experience.

Responsibilities

• Conducts chart reviews to verify InterQual-based care criteria.
• Assist in determining appropriate hospital setting and review elective surgeries and outpatient charts.
• Obtain patient records as required and coordinate UR with Medical Director as needed.
• Maximize hospital reimbursement and obtain necessary authorizations; follow up with payors.
• Review denials and assist in appeals; collaborate with HIM/coding staff to ensure accurate documentation.
• Communicate with hospital departments to ensure timely and accurate information flow.

Skills

Communication skills

Independent worker

InterQual criteria knowledge

Medical record review

ICD-10/CPT knowledge

Regulatory knowledge

PC proficiency

Education

Bachelor's Degree in Nursing

CCM certification (preferred)

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

*IMPORTANT NOTE: In lieu of benefits due to "per diem" status, 15% will be added to the hourly rate. Per diem employees are offered work on an "as-needed" basis.

POSITION SUMMARY

Performs clinically orientated medical chart reviews and other administrative tasks to meet the requirements of the medical center's utilization review plan, state and federal regulations, insurance company requirements for reimbursement.

POSITION REQUIREMENTS

• A Bachelor's Degree in Nursing preferred; three (3) years of clinical care or nursing experience; OR an equivalent combination of education and experience AND (2) two years’ experience Utilization Review.

Certificate Preferred

• CCM (certification in case management) is preferred.

License Required

• Must be licensed as a Registered Nurse by the State of Nevada, and remain active with all annual licensing requirements.
• Minimum of 1 year of case management or utilization management experience.
• Knowledge of InterQual or McKesson criteria preferred.
• Knowledge in conducting a medical record review for medical necessity.
• Knowledge of basic ICD-10, CPT coding knowledge preferred.
• Basic knowledge of regulations as set forth by The Centers for Medicare Medicaid Services.
• Skill in operating a personal computer utilizing a variety of software applications.
• Strong written and oral communication skills
• Skill and ability to work independently

POSITION ESSENTIAL FUNCTIONS

Chart Review

• Conducts chart review to determine that InterQual-based care criteria is met.
• Assist in determining if patients are in the correct hospital setting
• Review elective surgery schedule
• Review outpatient charts (observation)
• Obtains appropriate patient records as required by payor agencies and initiates the UR Medical Director as necessary for unwarranted admissions

Hospital Reimbursements

• Understand and demonstrates the requirements needed to maximize reimbursement to the hospital
• Assist in obtaining authorizations as needed; including follow-up
• Respond to insurance providers in a timely and thorough manner
• Communicates with various hospital departments in a meaningful manner
• Reviews denials and collaborates on appeals of denials
• Communicates with HIM staff and resolves discrepancies

Knowledge

• Condition 44 documentation and requirement; HINN notification letters, ABN-advance beneficiary notice, Important Letter from Medicare, etc
• Maintains practices consistent with the hospital's utilization review (UR) plan
• Reviews the plans components and is a member of the utilization review committee
• Obtains data and statistics addressed in the hospital's UR plan and presents information as needed
• Ensures appropriate and cost-effective healthcare services to patients

Documentation

• Demonstrates understanding and supports clinical documentation improvement strategies
• Ability to efficiently locate priority clinical information in a medical record, and to critically interpret that information as part of a treatment plan.
• Analyze clinical information to identify areas with potential for documentation improvement
• Demonstrates collaborative work relationship with coding staff to assure documentation of discharge diagnosis and co-morbidities are complete and accurately reflect the patient’s clinical status and care.
• Demonstrates collaborative work relationship with coding staff to assure documentation of discharge diagnosis and co-morbidities are complete and accurately reflect the patient's clinical status and care.
• Reviews medical records concurrently, recognizes opportunities for documentation improvement, and follows up with appropriate staff.
• Facilitates modifications to clinical documentation through collaborative interactions with physicians, nurses, and ancillary staff.

CARSON VALLEY HEALTH IS PROUD TO BE RECOGNIZED AS A FINALIST IN THE

"BEST PLACES TO WORK" - NORTHERN NEVADA, 2021, 2022, 2024, 2025 & 2026!

WE LOOK FORWARD TO WELCOMING YOU TO OUR TEAM!!

Utilization Review RN - Per Diem*

*IMPORTANT NOTE: In lieu of benefits due to "per diem" status, 15% will be added to the hourly rate. Per diem employees are offered work on an "as-needed" basis.

POSITION SUMMARY

Performs clinically orientated medical chart reviews and other administrative tasks to meet the requirements of the medical center's utilization review plan, state and federal regulations, insurance company requirements for reimbursement.

POSITION REQUIREMENTS

Minimum Education

• A Bachelor's Degree in Nursing preferred; three (3) years of clinical care or nursing experience; OR an equivalent combination of education and experience AND (2) two years’ experience Utilization Review.

Certificate Preferred

• CCM (certification in case management) is preferred.

License Required

• Must be licensed as a Registered Nurse by the State of Nevada, and remain active with all annual licensing requirements.

Minimum Work Experience

• Minimum of 1 year of case management or utilization management experience.
• Knowledge of InterQual or McKesson criteria preferred.
• Knowledge in conducting a medical record review for medical necessity.
• Knowledge of basic ICD-10, CPT coding knowledge preferred.
• Basic knowledge of regulations as set forth by The Centers for Medicare Medicaid Services.
• Skill in operating a personal computer utilizing a variety of software applications.
• Strong written and oral communication skills
• Skill and ability to work independently

POSITION ESSENTIAL FUNCTIONS

Chart Review

• Conducts chart review to determine that InterQual-based care criteria is met.
• Assist in determining if patients are in the correct hospital setting
• Review elective surgery schedule
• Review outpatient charts (observation)
• Obtains appropriate patient records as required by payor agencies and initiates the UR Medical Director as necessary for unwarranted admissions

Hospital Reimbursements

• Understand and demonstrates the requirements needed to maximize reimbursement to the hospital
• Assist in obtaining authorizations as needed; including follow-up
• Respond to insurance providers in a timely and thorough manner
• Communicates with various hospital departments in a meaningful manner
• Assists in ensuring appropriate room charges, patient status, discharge disposition, etc.
• Reviews denials and collaborates on appeals of denials
• Communicates with HIM staff and resolves discrepancies

Knowledge

• Condition 44 documentation and requirement; HINN notification letters, ABN-advance beneficiary notice, Important Letter from Medicare, etc
• Maintains practices consistent with the hospital's utilization review (UR) plan
• Reviews the plans components and is a member of the utilization review committee
• Obtains data and statistics addressed in the hospital's UR plan and presents information as needed
• Ensures appropriate and cost-effective healthcare services to patients

Documentation

• Demonstrates understanding and supports clinical documentation improvement strategies
• Ability to efficiently locate priority clinical information in a medical record, and to critically interpret that information as part of a treatment plan.
• Analyze clinical information to identify areas with potential for documentation improvement
• Demonstrates collaborative work relationship with coding staff to assure documentation of discharge diagnosis and co-morbidities are complete and accurately reflect the patient’s clinical status and care.
• Demonstrates collaborative work relationship with coding staff to assure documentation of discharge diagnosis and co-morbidities are complete and accurately reflect the patient's clinical status and care.
• Reviews medical records concurrently, recognizes opportunities for documentation improvement, and follows up with appropriate staff.
• Facilitates modifications to clinical documentation through collaborative interactions with physicians, nurses, and ancillary staff.

CARSON VALLEY HEALTH IS PROUD TO BE RECOGNIZED AS A FINALIST IN THE

"BEST PLACES TO WORK" - NORTHERN NEVADA, 2021, 2022, 2024, 2025 & 2026!

WE LOOK FORWARD TO WELCOMING YOU TO OUR TEAM!!

Per Diem positions have no guaranteed hours or set schedule. The position will fill in for individuals who take unplanned and/or planned time off.

Attachments (2)

CVH Standards of Behavior Final 032323.pdf