Description: The Utilization Review Nurse I (URN-I) functions as the
primary liaison between all third party payers and the Case Management
department. This job is responsible for communicating required clinical
information for the purpose of obtaining certification and approval for
payment for all applicable outpatient observation stays, inpatient admissions
and continued stay days. The URN-I is also responsible for review and
assessment of all scheduled surgical procedures. The URN-I works
collaboratively with all payors, as well as, Case Management staff, Physician
Advisor(s), physicians, healthcare team members, Registration Department,
Revenue Cycle team, Business Office staff and other key departments regarding
the payor certification process to ensure authorization is received for all
* Serves as the primary contact for all payors regarding utilization review and management issues.
* Performs concurrent payor reviews for medical appropriateness for patients placed in outpatient observation or in an inpatient setting according to payor guidelines, rules and regulations.
* Contacts the scheduling provider to get the correct status order for the scheduled procedure and/or secure documentation to support an ordered status or level of care.
* Ensures inpatient vs. outpatient scheduling criteria is met in accordance with the payor and CMS requirements (inpatient only procedures).
* Collaborates with the unit Case Manager, Social Worker, attending physician, and other healthcare team members to ensure medical appropriateness criteria, to develop an action plan to avert reductions in care or denials and to obtain all payor information that influence discharge planning activities.
* Provides all required clinical information to the payor according to the payors timeframe standards throughout the hospitalization to obtain certification approval for all services provided.
* Maintains a collaborative working relationship with the payors utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, discharge date, etc. as needed.
* Refers all cases that are denied by the payor to the Physician Advisor according to the Case Management department policy and procedure.
* Establishes and maintains professional, collaborative working relationships with the Business Office Registration Department, Revenue Cycle Department and other key departments to facilitate processes to ensure timely and appropriate reimbursement for services provided.
* Initiates and coordinates the payor appeal process for all concurrent denials including arranging a scheduled time for the attending physician and payor Medical Director to discuss the clinical situation.
* Conducts retrospective medical appropriateness review as identified by internal and external audit and/or payor denials.
* Performs other related job duties as assigned.
Required Education and Experience:
* Associates Degree in Nursing from an accredited college or university.
* 3 5 years of clinical experience and/or case management, utilization review, and/or discharge planning experience in an acute care setting, insurance company or other healthcare related field (home health, hospice, SNF, etc.).
Preferred Education and Experience:
* Bachelors Degree in Nursing from an accredited college or university.
* Experience working at or with insurance companies in the certification of healthcare services.
* Experience in conducting utilization review in a healthcare organization (Home Health/Hospice/Skilled Nursing Facility, Long-term care center, medical clinic, etc.)
* Case Management experience in an acute care setting.
* Experience in a leadership role such as a manager, charge nurse, team leader, etc.
Required Licensure/Certification/Specialized Training:
* RN licensure through the Texas State Board of Nurse Examiners.
Preferred Licensure/Certification/Specialized Training:
* ICD9 and CPT-4 Coding.
1500 S. Main Street
Fort Worth, Texas, 76104