Job Description

The Utilization Review Nurse completes inpatient admission and concurrent reviews for Health Choice members, considering Interqual criteria and other national standards, Policy and Procedures, and the member’s medical benefits. Reviews are made on-site, telephonically, and via fax. Assists and coordinates the discharge planning needs of the member with the facility staff, attending physician, the member, and his/her support.

Provide admission and concurrent review on inpatient members to ensure and facilitate quality and cost effective health care delivery:
* Review all inpatient admissions and initiate discharge planning in a timely manner
* Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of inpatient stay
* Conduct ongoing review for members in inpatient stay and utilize peer review, as necessary
* Communicate with UR Coordinator and Medical Director(s) for determination on reviews that do not meet criteria
* Provide notification to facility of determination
* Facilitate member’s transfers within contract facilities for ongoing inpatient stays
* Complete documentation in electronic medical record and claims systems
* Initiate interdepartmental coordination to ensure quality and timely care for members

Conduct discharge planning through proactive interaction with the physician, hospitalist, facility and member:
* Coordinate discharge planning to create member’s post-inpatient plan
* Interact with social worker, community agencies to identify alternate delivery of services
* Evaluate the need for case management and transition of care services following inpatient stay
* Coordinate transportation with contracted vendors following inpatient stay

Review medical records and claims data for acute and sub-acute levels of care.


Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled



* Knowledge of medical terminology
* Medical Records and Coding
* Interqual criteria
* Knowledge of Medicare and Medicaid regulations and guidelines
* ICD-9/ICD-10 (when applicable)
* CPT Codes and HCPCS codes

* Computer experience necessary
* Effective time management skills
* Effective interpersonal and communication skills

* Ability to use electronic medical record and claims systems
* Problem solving abilities
* Work cooperatively, positively, and collaboratively in an interdisciplinary team
* Ability to manage multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames

* High School Diploma or equivalent GED
* Associate’s degree or Bachelor’s degree from an accredited Nursing School preferred

* Previous UR/discharge planning experience preferred
* Chart review experience helpful
* Previous Medicaid/Medicare experience preferred

Certification and License:
Active, current, valid, unrestricted Arizona State Registered Nurse (RN) license or LPN

Application Instructions

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