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Utilization Management/Clinical Review RN

Job Code:  

Utilization Review is a safeguard against unnecessary and inappropriate medical care. It allows health care providers to review patient care from perspectives of medical necessity, quality of care, appropriateness of decision-making, place of service, and length of hospital stay.

• Ideal candidate must have hospital case management experience and solid utilization review experience applying evidenced based criteria sets along with experience determining level of care and medical necessity.

• Work collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization

• Facilitate patient care through effective utilization and monitoring of healthcare resources

• Coordinate care and services through the acute care episode and across the continuum

Qualifications and Education Requirements:

• Graduate of approved accredited nursing program, BSN preferred but not required

• Current license to practice as a Registered Professional Nurse

Preferred Skills:

• Broad clinical training and work experience sufficient to provide background in clinical management, continuing care and transitions of care

• Familiarity with health care insurances and regulations desirable

• Demonstrate knowledge of the principles of growth and development over the life span and can identify each patient’s age-specific needs