RN - Utilization Review Nurse

• Conducts pre-admission, admission, continued stay, re-admission, and discharge reviews each working day; utilizes the physician approved Interqual quality review criteria and Medical Center Utilization Management criteria concurrently.
• Provides review information to insurance companies as required to obtain certification numbers and approved days, documents this on the utilization review worksheets, and enters info into Meditech system.
• Reviews all cases that do not pass criteria (regardless of admission status order) with the attending physician and/or Utilization review physician.
• Contacts attending physician on 100% of cases not recertified by the contracted insurance companies.
• Screens all observation status patients for correct admission status.
• Participates in Care Management/Long Stay meetings with nursing and case management.
• Assists with the coordination of the appeal process for denied services, including writing appeal letters.
• Performs other duties as assigned.

• Associate Degree in Nursing

• 2 years nursing experience in a healthcare setting
• Experience and knowledge of utilization review activities, applying Interqual criteria.

• Current RN license in the state of Missouri