Job Description
Utilization Review Registered Nurse Job Summary Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones
POSITION SUMMARY Wage: 28.09-44.81 On-site. This full-time (0.9 status or 36 hours per week) position ensures the medical necessity for hospital services, admissions and continued stay are met per specific Medicare and commercial payor guidelines.
RESPONSIBILITIES Develops and implements effective utilization review functions resulting in maintaining an average length of stay that is financially justified for hospital operations.
Reviews all inpatient and observation admissions within 24 hours for appropriateness based on approved criteria and standards, Monday through Friday. All weekend admissions are reviewed on the following Monday.
Contacts physicians as required for information to justify admission or continued stay the same day of questionable stay.
Refers all cases where necessity for admission is questionable or potential for denial is identified to the attending physician or his/her designee for appropriate action after notifying the Discharge Planning/Social Services manager.
Develops and maintains a system to monitor and review certification completion.
Maintains complete and accurate documentation which reflects the status of hospital utilization, numbers and categories of cases reviewed, and denials by fiscal intermediaries. Documents and reports back follow-up.
Reviews and follows through the appeal process for patient stay denials.
Other duties may be assigned.
JOB SPECIFICATIONS Education and/or Experience Bachelor's degree required.
Five years of acute health care experience.
Two years experience related to utilization review preferred.
Certificates, Licenses, Registrations Holds or is eligible for current nursing licensor in the State of South Dakota.
Mandatory Basic and Advanced Life Support Training per policy
Benefits Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance.
Additional benefits for those qualifying include:
- Flexible Spending Account
- Employee Assistance Program for mental health
- Education Loan Program
- Community discounts including the Prairie Lakes Wellness Center
Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.
Job Tags
Full time, Part time, Work from home, Monday to Friday, Flexible hours, Weekend work