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Utilization Review (UR) Nurse

Wood County Hospital is now accepting application for a Utilization Review Nurse in our Quality and Accreditation department. The UR Nurse reviews patient records for medical necessity, level of care, length of stay, and authorization denials for inpatients and observation patients.  Assists in the clinical appeal process.  Collaborates with the healthcare team to coordinate care according to evidence-based, approved guidelines (e.g. Milliman Care Guidelines, Interqual).

 

Job Duties:

  • Serves as a resource for current standards of care, related to utilization review and case management.
  • Develops and enforces policies and procedures for the hospital related to compliance with regulatory and accreditation agencies, and other county, state, and federal agencies.
  • Utilized applicable criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning (e.g. Milliman Care Guidelines, Interqual).
  • Serves as a liaison between staff, physicians, hospital leadership, and insurance providers.
  • Tracks and reports trends of inappropriate utilization of resources of quality issues to the Director of Quality and Accreditation and/or the Chair of the Utilization Review Committee.
  • Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in hospital to comply with government and insurance company guidelines.

 

Shift Details:

Hours: Full Time, 40 hours per week

Shift: Day Shift, 7:00am - 3:30pm

 

Minimum Requirements:

Minimum Education:

  • Graduate of an accredited program for nursing education

Preferred Education:

  • Bachelor’s degree in Nursing (BSN) preferred.

Minimum License:

  • Current licensure to practice professional Nursing(RN) in the State of Ohio.

  • Current American Heart Association (AHA) Healthcare Provider CPS (BLS) certification required.

Minimum Experience:

  • Three years acute care nursing experience required. 
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