Registered Nurse RN - Utilization Review

Location:
Altru Hospital

1200 S.Columbia Rd.

Grand Forks, ND 58201

Pay Range: $66,955.20 - $100,422.40

Summary:
The Utilization Review RN is responsible for utilization review activities which include reviewing all admissions, continued stays and discharges based on established criteria and evaluation of medical necessity. Communicates with various third party payers. The utilization review RN is also responsible for utilization review activities which include concurrent, retrospective and denial reviews. Works to educate staff and providers regarding those criteria. The utilization review RN completes physician escalations as necessary and participates in the Utilization Management Committee.

Position is remote however, you must be local.

Essential Job Functions:

• Communicates with insurance companies, medical staff, nursing and the discharge team regarding appropriateness of admission and/or need for continued stay.
• Coordinates the appeal process with physicians and hospital staff for admission, continued stay, or quality denials. Communicates outcomes of external review. Coordinates and educates physicians and staff regarding level of care, orders, and documentation. Identifies cases for peer review and submits cases as appropriate.
• Completes all utilization review documentation according to established guidelines.
• Completes physician escalations and coordinates with physician advisor as necessary through established process.
• Reviews all admissions, continued stays, and discharges for appropriateness based on established criteria and evaluation of medical necessity, level of care, and various third party payer requirements.

Certification:

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources

Notes:

• Must hold an unencumbered nursing license prior to start.

Education:

• Preferred: Associates - Nursing

Work Experience:
• Preferred: A minimum of 3 years Related Experience

Physical Demands :
• Sit: Frequently (34-66%)

• Stand: Occasionally (5-33%)

• Walk: Frequently (34-66%)

• Stoop/Bend: Occasionally (5-33%)

• Reach: Frequently (34-66%)

• Crawl: Not Applicable

• Squat/Crouch/Kneel: Occasionally (5-33%)

• Twist: Occasionally (5-33%)

• Handle/Finger/Feel: Continuously (67-100%)

• See: Continuously (67-100%)

• Hear: Continuously (67-100%)

Weight Demands:
• Lift -Floor to Waist Level: Sedentary (<10 pounds)

• Carry: Sedentary (<10 pounds)

• Push/Pull: Sedentary (<10 pounds)

• Slide/Transfer: Not Applicable

Working Conditions:
• Indoor: Continuously (67-100%)

• Outdoor: Not Applicable

• Extreme Temperature: Not Applicable

Driving Requirement Definitions:

• Professional Drivers: Persons who drive as their main responsibility OR transport passengers or hazardous materials.
• Frequent Drivers: Persons whose main responsibility is not driving, but drive daily or almost daily.
• Occasional Drivers: Persons who drive from once per month to as frequently as once per week.
• Infrequent Drivers: Persons who are generally not expected to drive.

Driving Requirement for this position:
Infrequent Driver

Reference ID: R4688