Utilization Review Nurse

  • Aids Healthcare Foundation
  • Fort Lauderdale, FL , United States
  • Jan 05, 2018
Full time Registered Nurse

Job Description

Utilization Review is the process in which medical review determinations are made based on clinical guidelines and structured processes. This position reviews the utilization of the organization/plan’s resources against established criteria, monitors and evaluates the medical necessity, appropriateness and efficient use of health care services. The position also provides reports and recommendations for improved utilization of resources while maintaining quality of care to the UM/CM Mgr., Director of Managed Care and the Chief of Managed Care.

Essential Duties and Responsibilities:
Includes the following.  Other duties may be assigned.

  • Pre-admission, concurrent and retrospective acute care, sub-acute, hospice, transitional care & long term care to determine whether or not an admission is, or remains to be, reasonable and medically necessary, using established criteria, e.g., Milliman and Robertson, InterQual, Medicare or Medicaid, or AHF Best Practice criteria
  • Performs case reviews in a timely manner and maintains all required documentation of clinical reviews in the appropriate database. 
  • Issues authorizations to Providers and assists Plan Medical Director in the issuance of other required communications (such as denials) per established guidelines, and in compliance with all applicable Medicare or Medicaid guidelines.
  • Collaborates with the Primary Care Provider and/or attending physician, internal and external case managers, patient and/or family and other healthcare providers to provide continuity and quality of care in the most cost effective manner
  • Assists in the discharge planning process with both internal and external case managers/discharge planners and/or patient and family.
  • Concurrent Review and collaboration with internal case managers of all acute care, skilled nursing, acute rehabilitation, long term care, hospice and home with home care services admissions of Plan members.
  • Assesses each acute care hospital admission to determine the appropriate level of care, i.e., critical care, telemetry, step down, medical-surgical, administrative, etc.
  • Admission Reviews are performed within 72 hours of admission (for weekend admissions) and within 48 hrs. of all other admission, or as dictated by applicable policy and procedure.
  • Monitors and maintains Hospitalization Reports at the direction of UM/CM Mgr.
  • May attend clinical meetings with hospital based providers and staff regarding the care of plan members.
  • Coordinates closely with the Plan’s Medical Director, referring cases that do not appear to meet established criteria.
  • Compiles and analyzes data for utilization review management activities.
  • Maintains logs and statistics as directed by UM/CM Mgr.
  • Provides outpatient or pharmacy services utilization review, based on UM/CM Dept. needs.
  • Prepares or assists in preparing  weekly, monthly, quarterly and yearly and ad hoc utilization review reports as directed by UM/CM Mgr.
  • Assists in preparing an annual Utilization Management Program evaluation.

Participation in AHF Meetings/Committees
Attends AHF meetings as assigned.

Supervisory Responsibilities
This job has no supervisory responsibilities.


To perform this job successfully, an individual must be able to satisfactorily perform the essential duties.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Current Florida RN license
  • 3 or more years of recent medical/surgical or critical care nursing experience
  • 3 or more years of recent Utilization Review/Case Management Experience
  • Strong telephonic communication skills, ability to conduct high level clinical discussions with physicians and nurses
  • Ability to successfully work with various levels of professional staff; must work well independently and as part of a team

Language Skills
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.  Ability to write reports, business correspondence, and procedure manuals.  Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.  

Mathematical Skills
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent to draw and interpret bar graphs. College level algebra and statistics

Reasoning Ability
Ability to define problems, collect data, establish facts, and draw valid conclusions.  Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.