Job Description

Position Purpose: 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.

Responsibilities:

  • 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 including reviewing requested procedures, DME, home health or pharmaceutical needs while inpatient or upon discharge utilizing 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
  • 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

Education / Experience / Other Requirements

Education:

  • Associate’s degree or Bachelor’s degree from an accredited Nursing School required
  • Current unrestricted RN license for AZ

Years of Experience:

  • Previous UR/Discharge planning experience preferred
  • Previous Medicaid/Medicare experience preferred

Work Related Experience:

  • 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

Specialized Knowledge:

  • InterQual criteria
  • Strong knowledge of care management and care coordination
  • Proficiency in computer and technology utilization required, including, but not limited to: care management software, data-analytics software, Microsoft Office Products (Outlook, Excel, Power Point, Word, Visio)

Travel:

  • N/A

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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