UTILIZATION REVIEW NURSE-ED (PT NIGHTS)

Essential Duties

• Case Review and Assessment:
• Conduct thorough reviews of patient cases in the Emergency Department to assess the necessity and appropriateness of admissions, continued stays, and level of care.
• Utilize clinical knowledge and evidence-based guidelines to make determinations regarding the medical necessity of services.
• Collaboration and Communication:
• Work closely with physicians, nurses, and other healthcare professionals to gather necessary information and discuss care plans.
• Communicate with insurance providers to obtain authorization for treatments and services, ensuring compliance with payer requirements.
• Proactively facilitates throughput of all patients by monitoring for census peaks including surgical and procedural patient placement.
• Documentation and Reporting:
• Maintain accurate and detailed documentation of case reviews, decisions, and communications with healthcare providers and insurance companies.
• Prepare and submit reports as required, including utilization review reports and compliance documentation.
• Quality Improvement:
• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of care provided in the Emergency Department.
• Analyze utilization patterns and outcomes to identify opportunities for improvement and contribute to the development of best practices.
• Compliance and Policy Adherence:
• Ensure adherence to hospital policies, payer guidelines, and regulatory requirements related to utilization management.
• Stay informed about changes in healthcare regulations and payer requirements to ensure ongoing compliance.
• These are duties that MUST be performed in this job, with or without reasonable accommodation.

Non-essential Duties

• Assist with training and orientation of new staff members on utilization review processes and procedures.
• Support administrative tasks related to the utilization review process as needed.
• Participate in departmental meetings and contribute to discussions on process improvements and policy updates.

Required Experience

Preferred Experience

Required Licensure/Education

Preferred Education

Our Commitment to You

Compensation

• Base compensation within the positions pay range based on factors such as qualifications, skills, relevant experience, and/or trainin
• Premium pay such as shift differential, on-call
• Opportunity for annual increases based on performance

Benefits - .5 to 1.0 FTE

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Health Savings and Flexible Spending Accounts for eligible health care and dependent care expenses
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

Benefits - .001 to .49 FTE

• Paid Leave Hours accrued as you work

Employee Health Requirements

• Exposure/Sensory Requirements:
• Exposure to:
• Chemicals: Refer to MSDS Sheets
• Video Display Terminals: Extreme
• Blood and Body Fluids: Minimal potential
• TB or Airborne Pathogens: Minimal potential
• Sensory requirements (speech, vision, smell, hearing, touch):
• Speech: Needed for presentations, training, telephone communication, facilitating meetings.
• Vision: Needed for computer entry, reading memos and literature.
• Smell: Needed for electrical/fire safety.
• Hearing: Needed for telephone communication, meetings and listening to employee concerns.
• Touch: Needed for writing, computer entry, filing.
• Activity/Lifting Requirements
• Percentage of time during the normal workday the employee is required to:
• Sit: 50%
• Twist: 0%
• Stand: 35%
• Crawl: 0%
• Walk: 10%
• Kneel: 0%
• Lift: 5%
• Drive: 0%
• Squat: 0%
• Climb: 0%
• Bend: 0%
• Reach above shoulders: 0%
• The weight required to be lifted each normal workday according to the continuum described below:
• Up to 10 lbs: Occasionally
• Up to 20 lbs: Occasionally
• Up to 35 lbs: Not Required
• Up to 50 lbs: Not Required
• Up to 75 lbs: Not Required
• Up to 100 lbs: Not Required
• Over 100 lbs: Not Required
• Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.):
• Brief case, notebook, computer, printed material-transported from one location/meeting to another.
• Maximum consecutive time (minutes) during the normal workday for each activity:
• Sit: 480
• Twist: 0
• Stand: 240
• Crawl: 0
• Walk: 60
• Kneel: 0
• Lift: 5
• Drive: 0
• Squat: 0
• Climb: 0
• Bend: 0
• Reach above shoulders: 0
• Repetitive use of hands (Frequency indicated):
• Simple grasp up to 10 lbs. Normal weight:
• Pushing & pulling Normal weight:
• Fine Manipulation: Calculator, keyboard, writing instruments
• Repetitive use of foot or feet in operating machine control: Not Required
• Environmental Factors & Special Hazards
• Environmental Factors (Time Spent):
• Inside hours: 8
• Outside hours : 0
• Temperature: Normal Range
• Lighting: Average
• Noise levels: Average
• Humidity: Normal Range
• Atmosphere:
• Special Hazards: None
• Protective Clothing Required: None