RN-Utilization Review (S)

It's more than a career, it's a calling.

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Worker Type:

Regular

Job Summary:

Evaluates the medical necessity and appropriateness of hospital admissions and surgical procedures. Ensures payors receive clinical information to support services provided by hospital. Ensures hospital receives authorization from payor.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Discusses with payor regarding criteria and payor decision.
• Escalates denials to physician (advisor, attending consultant, outside consultant) for peer to peer consideration.
• Documents outcome in electronic medical record.
• Participates with other members of team regarding opportunities for improvement in standard work.
• Performs review of pre-admission, perioperative, and post operative surgical cases.
• Performs other utilization management tasks as assigned.
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• Two years’ registered nurse experience

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

State of Work Location: Illinois

• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location: Missouri

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Missouri Division of Professional Registration

State of Work Location: Oklahoma

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)

State of Work Location: Wisconsin

• Registered Nurse (RN) Issued by Compact State
• Or
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift:

Day Shift (United States of America)

Employee

Department:

8746030033 Sys Utilization Management

Scheduled Weekly Hours:

40

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).

• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.

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SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.