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University of Mississippi Medical Center is the state’s only academic health science center and has six schools of study: medicine, nursing, dentistry, health
RN - Utilization Reviewer
Location
United States
Posted
10 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
RN - Utilization Reviewer
University of Mississippi Medical Center
Role Description Accountable to perform utilization management services for designated patient case load, including: - Prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. - Reports quality of care issues identified during the utilization management process to the appropriate manager. - Perform job duties in accordance with the medical center's purpose. Qualifications - Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management. - InterQual experience preferred. Requirements - Valid RN license. - CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred. - Knowledge of the aspects of utilization review. - Excellent interpersonal verbal and written communication and negotiation skills. - Skills in the use of personal computers and related software applications. - Ability to gather data, compile information, and prepare reports. - Ability to identify process improvements. - Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes. - Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement. - Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families. - Demonstrate commitment to the organization’s mission and the behavioral expectations in all interactions and in performing all job duties. - Ability to use medical necessity guidelines with minimal supervision. - Equipped to work remotely to include hardware with high speed internet via cable and Windows 10. Responsibilities - Performs all aspects of prospective, concurrent, retrospective, and denials review for individual cases. - Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals. - Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients. - Collects, analyzes, and addresses variances from the plan of care path with physician and/or other members of the healthcare team. - Uses concurrent variance data to drive practice changes and positively impact outcomes. - Documents key clinical path variances and outcomes which relate to areas of direct responsibility. - Applies approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays. - Identifies at-risk populations using approved screening tool and follows established reporting procedures. - Communicates with third party payers to facilitate covered day reimbursement certification for assigned patients. - Works collaboratively and maintains active communication with physicians, nursing, and other members of the interdisciplinary care team. - Addresses/resolves system problems impeding diagnostic or treatment progress. - Promotes individual professional growth and development by meeting requirements for mandatory/continuing education. - Actively participates in clinical performance improvement activities. Environmental and Physical Demands - Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold. - Occasional working hours beyond regularly scheduled hours. - Occasional activities subject to significant volume changes of a seasonal/clinical nature. - Occasional lifting/carrying up to 25 pounds. - Frequent sitting, occasional standing, and frequent walking. Time Type Part time FLSA Designation/Job Exempt Yes Pay Class Salary FTE % 100 Work Shift Benefits Eligibility Job Posting Date 06/8/2026
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