注册护士，利用管理
RN Utilization Management
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职位概述
利用管理护士对先决批准、网络例外、福利查询、住院医疗/手术入院和门诊程序进行临床审查，针对提供者和其他合同业务线。该职位通过解读和审查基于证据的标准、临床指南、公司指南和政策以及法规和标准，评估和评价服务的效率和适当性。任职者还根据证据促进适当的护理和质量，以实现成本效益和成本控制措施。
要求
教育背景
护理学士学位优先考虑。
资质认证
持有注册护士（RN）执照，且在相关司法管辖区有效、当前、无限制并被认可，在履行工作职责的州内持有效执照。
工作经验
至少四年临床护理经验，涵盖以下领域之一：内科外科护理、外科护理、重症监护或危重症护理。
具有利用管理及/或医疗审查经验者优先考虑。
核心技能与能力
口头与书面沟通
细节关注
熟练使用基本的计算机技能，如 Microsoft Office 中的 Word、Excel 和 Outlook，包括能够操作多个系统和打字。
能够通过批判性思维进行优先级排序和做出合理的护理判断。
能够建立协作关系。
能够解释复杂的文档。
能够独立工作。
技能
• 积极倾听
• 分析决策
• 批判性思维
• 数据分析
• 教育发展
• 人际关系管理
• Microsoft Outlook
• Microsoft SharePoint
• Microsoft Word
• 口头沟通
• 问题敏感度
• 良好判断力
• 团队发展
• 时间管理
• 书面沟通
职责
• 与医疗保健提供者和内部员工合作，促进护理质量、成本效益、可及性和服务等级的适当性。
• 进行并监控临床审查案例，确保住院和门诊服务、诊断程序、非网络服务和手术的医疗必要性；记录所有相关和具体信息；并筛选、优先处理和组织决定请求。
查看英文原文
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Job Summary
Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.Requirements
EDUCATION
Bachelor's degree in Nursing preferred.
LICENSING/CERTIFICATION
Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required.
EXPERIENCE
Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.
Experience in utilization management and/or medical review preferred.
ESSENTIAL SKILS & ABILITIES
Oral & Written Communication
Attention to Detail
Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
Ability to prioritize and make sound nursing judgments through critical thinking.
Ability to build collaborative relationships.
Ability to interpret complex documentation.
Ability to work independently.
Skills
• Active Listening• Analytical Decision Making• Critical Thinking• Data Analysis• Educational Development• Interpersonal Relationship Management• Microsoft Outlook• Microsoft SharePoint• Microsoft Word• Oral Communications• Problem Sensitivity• Sound Judgment• Team Development• Time Management• Written CommunicationResponsibilities
• Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.• Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards.• Performs other duties as assigned.• Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.• Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.• Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.• Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively.Certifications
Registered Nurse (RN) - Arkansas State Board of NursingSecurity Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
RegularADA Requirements
2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.
Originally posted on Himalayas