Trinity Health System
Utilization Review RN at Trinity Health System.
Job Summary / Purpose Responsible for reviewing medical records to determine appropriate admission status and continued hospitalization. Collaborates with attending physicians, second‑level physician reviewers, Care Coordination staff, and payer communications to apply evidence‑based guidelines, identify denial root causes, and implement prevention strategies.
Responsibilities
Conduct admission and continued stay reviews per Care Coordination Utilization Review guidelines, ensuring hospitalization is warranted.
Ensure compliance with hospital policies, peer review organizations, Joint Commission, and payer criteria.
Review records for accurate patient status orders and resolve deficiencies with providers.
Communicate timely outcomes with physicians, payers, care coordinators, and other stakeholders.
Collaborate with RN care coordinators and physician reviewers to support appropriate status decisions.
Coordinate peer‑to‑peer interactions between hospital and insurance providers when appropriate.
Document working DRG at initial review per directives.
Engage Denials RN/Revenue cycle to discuss denial prevention opportunities.
Maintain required education and hospital policy adherence.
Participate in performance improvement teams and perform other duties as assigned.
Minimum Qualifications Required Education and Experience
Minimum two (2) years of acute hospital clinical experience or a Master’s degree in Case Management or Nursing; alternatively 1 year of experience with a Bachelor’s in Nursing (BSN).
At least five (5) years of nursing experience.
Required Licensure and Certifications
RN license in the state(s) covered.
Certified Case Manager (CCM), Accredited Case Manager (ACM‑RN), or UM Certification preferred.
Required Knowledge, Skills, and Abilities
Basic Life Support (BLS) certification within 3 months of hire (hospital location).
Pass annual Inter‑rater reliability test for utilization review products.
Proficiency in clinical guidelines (MCG/InterQual) and managed‑care payer environment.
Critical thinking, problem‑solving, and effective communication with multiple stakeholders.
Team‑player who can work independently in a fast‑paced environment.
Knowledge of CMS standards and ability to prioritize work and delegate.
Highly organized with excellent time‑management skills.
Seniority Level
Mid‑Senior level
Employment Type
Full‑time
Job Function
Health Care Provider
Industry
Hospitals and Health Care
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Job Summary / Purpose Responsible for reviewing medical records to determine appropriate admission status and continued hospitalization. Collaborates with attending physicians, second‑level physician reviewers, Care Coordination staff, and payer communications to apply evidence‑based guidelines, identify denial root causes, and implement prevention strategies.
Responsibilities
Conduct admission and continued stay reviews per Care Coordination Utilization Review guidelines, ensuring hospitalization is warranted.
Ensure compliance with hospital policies, peer review organizations, Joint Commission, and payer criteria.
Review records for accurate patient status orders and resolve deficiencies with providers.
Communicate timely outcomes with physicians, payers, care coordinators, and other stakeholders.
Collaborate with RN care coordinators and physician reviewers to support appropriate status decisions.
Coordinate peer‑to‑peer interactions between hospital and insurance providers when appropriate.
Document working DRG at initial review per directives.
Engage Denials RN/Revenue cycle to discuss denial prevention opportunities.
Maintain required education and hospital policy adherence.
Participate in performance improvement teams and perform other duties as assigned.
Minimum Qualifications Required Education and Experience
Minimum two (2) years of acute hospital clinical experience or a Master’s degree in Case Management or Nursing; alternatively 1 year of experience with a Bachelor’s in Nursing (BSN).
At least five (5) years of nursing experience.
Required Licensure and Certifications
RN license in the state(s) covered.
Certified Case Manager (CCM), Accredited Case Manager (ACM‑RN), or UM Certification preferred.
Required Knowledge, Skills, and Abilities
Basic Life Support (BLS) certification within 3 months of hire (hospital location).
Pass annual Inter‑rater reliability test for utilization review products.
Proficiency in clinical guidelines (MCG/InterQual) and managed‑care payer environment.
Critical thinking, problem‑solving, and effective communication with multiple stakeholders.
Team‑player who can work independently in a fast‑paced environment.
Knowledge of CMS standards and ability to prioritize work and delegate.
Highly organized with excellent time‑management skills.
Seniority Level
Mid‑Senior level
Employment Type
Full‑time
Job Function
Health Care Provider
Industry
Hospitals and Health Care
#J-18808-Ljbffr