Registered Nurse Utilization Review

Description
Provides health care services regarding admissions, case management, discharge planning and utilization review.

Responsibilities

• Reviews admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases.
• Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals.
• Assesses and coordinates discharge planning needs with healthcare team members.
• May prepare statistical analysis and utilization review reports as necessary.
• Oversees and coordinates compliance to federally mandated and third party payer utilization management rules and regulations.

Qualifications
Licensure / Certification / Registration

• Required Credential(s):
  • Registered Nurse credentialed from the Wisconsin Board of Nursing obtained prior to hire date or job transfer date. Licensure from the Wisconsin Board of Nursing OR current home state license if considered multi-state/Compact State.

Education

• Diploma from an accredited school/college of nursing required. OR Required professional licensure at time of hire.