13 hours

Registered Nurse - Utilization Review

Kenosha, WI
  • Job Code
    4763
  • Jobs Rated
    118th
Jobid: 4763
Job Title: Registered Nurse - Utilization Review
Location: Kenosha, WI
Job type: Full-time
Category: Nursing
Description:
  • POSITION PURPOSE
    • Performs concurrent and retrospective clinical documentation reviews utilizing evidence based criteria, discharge indicators, and clinical judgment for all patients and payers. Strives to maintain and improve compliance of regulations as required by CMS and other regulatory agencies. Assists in maintaining and ensuring medical necessity compliance and revenue integrity, improving reimbursement, while optimizing hospital efficiency and decreasing clinical denials.
  • MINIMUM EDUCATION REQUIRED
    • Associate Degree: Nursing
  • MINIMUM EXPERIENCE REQUIRED
    • 1 to 3 years
  • LICENSES / CERTIFICATIONS REQUIRED
    • Licensure to be eligible to practice as a Registered Nurse or Graduate Nurse in the State of Wisconsin.
  • KNOWLEDGE, SKILLS & ABILITIES REQUIRED
    • Graduate of an accredited nursing program.
    • Three to five years of previous related experience preferred.
    • Strong clinical background in acute care nursing preferred.
    • Ability to work independently and be attentive to details, as well as work well as part of a team.
    • General knowledge of CMS and regulatory requirements, case management philosophies and coding guidelines.
    • Strong organizational, analytical, and interpersonal skills.
    • Possess proficient computer and keyboarding skills with ability to utilize and achieve accurate use of related software.
  • PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES
    • Performs concurrent and retrospective review of clinical services as documented in the medical record. Abstracting, analyzing, and interpreting, all information.
    • Applies clinical information to evidence based criteria, Milliman Care Guidelines (MCG), for determining medical necessity, compliance, and ensuring revenue integrity.
    • Consults with Executive Health Resources (EHR) for support in reviewing clinical documentation to achieve regulatory compliance and effective managing of clinical care while maintaining sound financial performance.
    • Remains knowledgeably current with CMS and all regulatory guidelines regarding Utilization.
    • Collaborates with multidisciplinary team to include but not limited to physicians, patient accounting, coding staff, and social services to ensure optimal reimbursement and avoidance of denials.
    • Displays general understanding of coding concepts.
    • Monitors and educates multidisciplinary team on clinical documentation to reduce compliance risks.


Industry

  • Health Care / Social Assistance

Jobs Rated Reports for Registered Nurse

Posted: 2019-08-22 Expires: 2019-09-21

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Registered Nurse - Utilization Review

Froedtert South
Kenosha, WI

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Registered Nurse
118th2018 - Registered Nurse
Overall Rating: 118/220
Median Salary: $70,000

Work Environment
Poor
166/220
Stress
High
173/220
Growth
Good
53/220
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