As a Utilization Review RN you are responsible for prospective, retrospective and concurrent Utilization Review activities. You will be a member of the Multidisciplinary Team, and monitors the documentation for accuracy and clinical compliance. Additionally you will be also responsible for organizing, directing and coordinating Utilization Review activities within the organization in accordance with standards of State and Federal regulations; and in accordance with accreditation and other guidelines
Perform medical necessity reviews for selected procedures and services.
Provide timely and thorough case screening to identify case management needs and make appropriate referrals to Case Managers.
Collaborate timely, professionally and effectively with members/designees, families and members of the health care team to maximize outcomes.
Identify discharge needs and collaborate with health care providers to facilitate a timely discharge to an appropriate level and location of care. Closely collaborate with Case Managers when facilitating discharge for Case Management members.
Educate both provider and member to promote self-care and self-advocacy.
Realize positive outcomes in terms of the quality, safety and cost-effectiveness of health care services provided.
Deliver timely follow up to outstanding utilization management issues and inquiries made via overnight voicemail and /or emails.
Develop and maintain cooperative relationships with other parts of the organization. Consult with colleagues/experts as needed. Collaborate willingly with others to ensure the best outcomes for members served.
Develops and maintains positive member relationships; enhancing customer service
Adheres to all company and department policies and procedures in confidentiality, regulatory or contractual mandates and HR policy.
- Graduate from an accredited School of Nursing. Bachelors Degree in Nursing, preferred.
- Current license to practice as a Registered Professional Nurse in New York State.
- Minimum of five (5) years clinical experience, required. Previous experience in case management, disease management, quality management or patient education, preferred.
Transforming care, optimizing patient satisfaction and creating better patient outcomes are just some of the things our talented team members are doing at North Shore-LIJ each and every day. As a culture committed to providing our customers with the highest quality service, we stand behind our core values: Patients first; Caring; Excellence; Innovation; Integrity and Teamwork. It is our commitment and our culture that sets us apart from others and is the cornerstone of everything we do. Join an organization whose team members are valued, cared for and offered continuous opportunities to grow. Click on the link to learn more about us: www.northshorelij.com/goals
Please note: North Shore-LIJ is a smoke-free environment. Smoking and the use of tobacco products is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. Free smoking cessation programs and quit medications are offered to team members who wish to quit through the North Shore-LIJ Center for Tobacco Control.