• Utilization Review RN

    Job ID
    Employment Type
    Full Time
    Hours Per Week
    350 7th Street North
  • Overview

    The UR Nurse monitor’s adherence to Hospital’s Utilization Review Plan to ensure the effective and efficient use of hospital services. Assists physicians and mid-level providers in the determination of the appropriate level of care assignment both at the time of initial placement in the hospital and as the patient’s clinical condition evolves. Monitors the appropriateness of hospital admissions and extended hospital stays.


    • Reviews medical records for appropriate application of medical necessity criteria to determine the appropriateness of admission and/or continued stay and readiness for discharge using InterQual criteria and clinical expertise.
    • Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Communicates patient admission status information to business operations staff in a timely manner such that patients obtain timely and appropriate care in the hospital setting as required by their clinical conditions.
    • Performs concurrent clinical review for patients to ensure that extended stays are medically justified and are so documented in patient's medical. Communicates with attending physician regarding patients clinical condition, signs and symptoms as needed to ensure the patient’s admission status is supported by the physician’s documentation consistent with industry accepted guidelines and payer rules/regulations.
    • Works in conjunction with Clinical Documentation Improvement nurses to identify the Working DRG for patients admitted as inpatients and ensure the Working DRG is entered into the Cerner UM Module in order to calculate the GMLOS.
    • Enters clinical reviews into the UM Module within Cerner and works with the Utilization Review Coordinators to ensure necessary concurrent clinical information is transmitted to third-party payers and required by the payer and/or any payment contract with facility.
    • Ensures prior authorizations are entered into the UM Module for those services requiring prior authorization from the patient’s third-party payer. Enters approved hospital days into the UM Module when received by the patient’s payer.
    • Participates in daily departmental planning meetings and meets with the clinical team to guide the patient’s discharge plan.
    • Assure the RN Care Coordinator assigned to the patient is aware of the self-pay status of patients and make necessary referrals to financial counselors and/or hospital’s contracted financial counseling agencies, members of the healthcare team regarding target length of stay (LOS), acute care criteria, pay requirements, resource utilization, and care options to meet patient needs.
    • Develops and maintains relationships with third-party payers necessary to coordinate the appropriate utilization of hospital resources and meet the clinical needs of assigned patients.
    • Refers to the Utilization Review Physician Advisor all cases that do not meet established guidelines for admission or continued stay consistent with the arrangement with the Physician Advisor.
    • Performs concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines.
    • Predicts and plans for patient’s needs from admission through acute and sub-acute care and post-discharge, in collaboration with the patient’s third-party payer and providers.
    • Acts as a liaison with the RN Care Coordinators and Care Coordination Social Workers to facilitate the appropriate utilization of hospital resources and timely discharge. Tracks and reports trends of inappropriate utilization of resources to the Utilization Review Manager.
    • Participates in a regular rotation of weekend and after-hours coverage in order to meet Department needs as determined by the Director of Case Management.
    • Supports nThrive’s Compliance Program by adhering to policies and procedures pertaining to HIPAA, FDCPA, FCRA, and other laws applicable to nThrive’s business practices. This includes: becoming familiar with nThrive’s Code of Ethics, attending training as required, notifying management or nThrive’s Helpline when there is a compliance concern or incident, HIPAA-compliant handling of patient information, and demonstrable awareness of confidentiality obligations.



    • Bachelor's degree in nursing (BSN) or Associate degree in nursing.
    • 3+ years of direct patient care experience as a registered nurse.
    • Knowledge of Medicare and Medicaid payment rules, policies and regulations.
    • Strong written and verbal communication skills.
    • Knowledge of MS Office products such as MS Word and MS Outlook.
    • Ability to evaluate medical records and other health care data.
    • Effective and professional presentation skills.


    Preferred Skills

    • Certification in care coordination or utilization review.
    • Prior experience as an RN Care Coordinator.

    About nThrive


    Be Inspired. Ignite Change. Transform Health Care. 

    From Patient-to-PaymentSM, nThrive provides all the technology, advisory expertise, services, analytics and education programs health care organizations need to thrive in the communities they serve. Our colleagues share a united passion to help health care organizations strengthen their financial position, which translates to accessible, quality care for all. This passion fuels our drive to innovate and participate in community outreach through the nThrive CARES program. Our colleagues are encouraged to think differently and empowered to make a lasting impact that ensures our health care providers, and our world, are healthy and productive.


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