2nd Annual Fund Raiser

Career Center

JOB TITLE: Utilization Review Nurse

REPORTS TO: Utilization Review Coordinator

JOB SUMMARY: A professional nurse who promotes optimum delivery of care to patients by compiling and analyzing documentation for Medicare reimbursable services and through Utilization Review and Quality Improvement activities.

QUALIFICATIONS:

  • All qualifications in Community Health Nurse job description.
  • Minimum of two years experience in community health nursing.
  • Thorough knowledge of Medicare guidelines and the skill to generate reimbursable documentation.
  • Excellent verbal and written communication skills.

ESSENTIAL JOB RESPONSIBILITIES:

  • Demonstrates current knowledge of federal and state rules and regulations.
  • Reviews Medicare, Medicaid, and commercial insurance orders and documentation for certification/recertification prior to submission to physician and billing.
  • Reports to supervisor as appropriate any unusual circumstances or staff learning needs regarding reimbursable documentation.
  • Assists billing and data entry personnel as needed with proper ICD-9CM coding of diagnosis and procedures.
  • Conducts/assists with quarterly Utilization Review Chart audits and functions as chairperson for Utilization Review meetings as needed.
  • Reports findings of Utilization Review to Administration and staff and offers recommendations as needed.
  • Assists with documentation review.
  • Participates with Quality Improvement activities as assigned.
  • Orients Community Health Nurses to documentation requirements and functions as resource person for Community Health Nurses, Home Health Aides, and other members of the treatment team.
  • Functions as Community Health Nurse when necessary.
  • Participates in professional organizations.
  • Attends continuing education programs.

PHYSICAL DEMANDS:

  • Medium carrying or lifting (up to 35 lbs.)
  • Reaching, handling, fingering, feeling
  • Sedentary but able to negotiate through doors and in confined spaces (supply closet)
  • Seeing - visual acuity and depth perception
  • Hearing - express or communicate ideas or sounds.

NON-ESSENTIAL JOB RESPONSIBILITIES:

  • Performs other duties as assigned by Utilization Review Coordinator or other Administrative staff.