UTILIZATION REVIEW NURSE-ED

Riverside Healthcare is seeking a dedicated and experienced Utilization Review Nurse to join our Emergency Department team in Kankakee, Illinois. The Utilization Review Nurse will play a crucial role in ensuring that patients receive appropriate and effective care while optimizing resource utilization. This position involves reviewing patient cases, assessing the necessity of admissions and continued stays, and collaborating with healthcare providers to enhance patient outcomes and hospital efficiency by managing documentation and optimizing resource utilization. 

Essential Duties

Case Review and Assessment:

• Conduct thorough reviews of patient cases in the Emergency Department to assess the necessity and appropriateness of admissions, continued stays, and level of care.
• Utilize clinical knowledge and evidence-based guidelines to make determinations regarding the medical necessity of services.

Collaboration and Communication:

• Work closely with physicians, nurses, and other healthcare professionals to gather necessary information and discuss care plans.
• Communicate with insurance providers to obtain authorization for treatments and services, ensuring compliance with payer requirements.
• Proactively facilitates throughput of all patients by monitoring for census peaks including surgical and procedural patient placement.  

Documentation and Reporting:

• Maintain accurate and detailed documentation of case reviews, decisions, and communications with healthcare providers and insurance companies.
• Prepare and submit reports as required, including utilization review reports and compliance documentation.

Quality Improvement:

• Participate in quality improvement initiatives to enhance the efficiency and effectiveness of care provided in the Emergency Department.
• Analyze utilization patterns and outcomes to identify opportunities for improvement and contribute to the development of best practices.

Compliance and Policy Adherence:

• Ensure adherence to hospital policies, payer guidelines, and regulatory requirements related to utilization management.
• Stay informed about changes in healthcare regulations and payer requirements to ensure ongoing compliance.

These are duties that MUST be performed in this job, with or without reasonable accommodation.

Non-essential Duties

• Assist with training and orientation of new staff members on utilization review processes and procedures.
• Support administrative tasks related to the utilization review process as needed.
• Participate in departmental meetings and contribute to discussions on process improvements and policy updates.

Required Experience

• Minimum of 3 years of clinical experience in an Emergency Department setting.

Preferred Experience

• Prior experience in utilization review or case management is preferred
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills for effective collaboration with healthcare providers and insurance representatives.
• Proficiency in electronic health record (EHR) systems and utilization review software.
• Ability to work independently and manage multiple tasks efficiently in a fast-paced environment.
• Knowledge of InterQual and/or MCG and local and national coverage determinations.  

Required Licensure/Education

• Active Registered Nurse (RN) license in the State of Illinois.
• Associates Degree of Nursing (AND)
• *All new RN;s starting on or after 1/1/25 must complete their Bachelors of Science in Nursing within three years.

Preferred Education

•  Bachelors Degree in Nursing (BSN) from an accredited institution or higher degree*

Employee Health Requirements

Exposure/Sensory Requirements:

Exposure to:

• Chemicals: Refer to MSDS Sheets
• Video Display Terminals: Extreme
• Blood and Body Fluids: Minimal potential
• TB or Airborne Pathogens: Minimal potential

Sensory requirements (speech, vision, smell, hearing, touch):

• Speech: Needed for presentations, training, telephone communication, facilitating meetings.
• Vision: Needed for computer entry, reading memos and literature.
• Smell: Needed for electrical/fire safety.
• Hearing: Needed for telephone communication, meetings and listening to employee concerns.
• Touch: Needed for writing, computer entry, filing.

Activity/Lifting Requirements

Percentage of time during the normal workday the employee is required to:

Sit: 50%

Twist: 0%

Stand: 35%

Crawl: 0%

Walk: 10%

Kneel: 0%

Lift: 5%

Drive: 0%

Squat: 0%

Climb: 0%

Bend: 0%

Reach above shoulders: 0%

The weight required to be lifted each normal workday according to the continuum described below:

Up to 10 lbs: Occasionally

Up to 20 lbs: Occasionally

Up to 35 lbs: Not Required

Up to 50 lbs: Not Required

Up to 75 lbs: Not Required

Up to 100 lbs: Not Required

Over 100 lbs: Not Required

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.):

Brief case, notebook, computer, printed material-transported from one location/meeting to another.

Maximum consecutive time (minutes) during the normal workday for each activity:

Sit: 480

Twist: 0

Stand: 240

Crawl: 0

Walk: 60

Kneel: 0

Lift: 5

Drive: 0

Squat: 0

Climb: 0

Bend: 0

Reach above shoulders: 0

Repetitive use of hands (Frequency indicated):

Simple grasp up to 10 lbs. Normal weight:

Pushing & pulling Normal weight:

Fine Manipulation: Calculator, keyboard, writing instruments

Repetitive use of foot or feet in operating machine control: Not Required

Environmental Factors & Special Hazards

Environmental Factors (Time Spent):

Inside hours: 8

Outside hours : 0

Temperature: Normal Range

Lighting: Average

Noise levels: Average

Humidity: Normal Range

Atmosphere:

Special Hazards: None

Protective Clothing Required: None