Summary The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention. Responsibilities + Completes and enters inpatient and observation admission review against standard criteria per payer guidelines + Prioritizes observation case review + Assists with level of care in collaboration with attending provider + Enters working diagnosis-related groups (DRGs) in the electronic medical record + Submits clinical information to payer per payer requirements + Completes continued stay reviews every 3 days or more often if required + Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated + Communicates with physician advisors related to status concerns or denials + Updates auth/cert screen in the electronic medical record + Works assigned queues in the electronic medical record + Communicates with authorization coordinator + Communicates in-house high dollar case information Completes assigned goals Requirements, Preferences and Experience Experience Minimum: RN with 3 years of clinical experience Experience Preferred: RN with 3 years of clinical experience Education Minimum: Diploma or Associate Degree in Nursing Education Preferred: BSN or MSN Special Skills Minimum: Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations. Licensure Minimum: RN Licensure Preferred: CCM;ACM About Baptist Memorial Health Care At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey. At Baptist, We Offer: + Competitive salaries + Paid vacation/time off + Continuing education opportunities + Generous retirement plan + Health insurance, including dental and vision + Sick leave + Service awards + Free parking + Short-term disability + Life insurance + Health care and dependent care spending accounts + Education assistance/continuing education + Employee referral program Job Summary: Position: 19737 - RN-Utilization Review Facility: BMHCC Corporate Office Department: HS Case Mgmt Administration Corporate Category: Nurse RN Type: Clinical Work Type: PRN Work Schedule: Days Location: US:TN:Memphis Located in the Memphis metro area REQNUMBER: 22632