Utilization Review is a safeguard against unnecessary and inappropriate medical care. It allows health care providers to review patient care from perspectives of medical necessity, quality of care, appropriateness of decision-making, place of service, and length of hospital stay.
Ideal candidate must have hospital case management experience and solid utilization review experience applying evidenced based criteria sets along with experience determining level of care and medical necessity.
Work collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization
Facilitate patient care through effective utilization and monitoring of healthcare resources
Coordinate care and services through the acute care episode and across the continuum
Qualifications and Education Requirements:
Graduate of approved accredited nursing program, BSN preferred but not required
Current license to practice as a Registered Professional Nurse
Broad clinical training and work experience sufficient to provide background in clinical management, continuing care and transitions of care
Familiarity with health care insurances and regulations desirable
Demonstrate knowledge of the principles of growth and development over the life span and can identify each patient’s age-specific needs