Utilization Review Nurse
Steward Health Choice is dedicated to improving the health and well-being of the people and communities we serve.
Steward Health Choice believes in a personal approach to health care right in your community. We built our health care plan around you. Our goal is to give you quality health care, programs, and services to support you on your path to wellness.
Steward Health Choice provides exceptional customer service and culturally competent care through:
- Compassionate and responsive member services team
- Collaboration with community physicians to help members get the health care they need.
- Providing culturally competent health care, including extensive translation and interpretation services
- Health programs to help members and their families stay healthy
Position Purpose: The Utilization Review Nurse completes inpatient admission and concurrent reviews for Health Choice members, considering Interqual criteria and other national standards, Policy and Procedures, and the member’s medical benefits. Reviews are made on-site, telephonically, and via fax. Assists and coordinates the discharge planning needs of the member with the facility staff, attending physician, the member, and his/her support.
- Review all inpatient admissions and initiate discharge planning in a timely manner
- Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of inpatient stay
- Conduct ongoing review for members in inpatient stay including reviewing requested procedures, DME, home health or pharmaceutical needs while inpatient or upon discharge utilizing peer review, as necessary
- Communicate with UR Coordinator and Medical Director(s) for determination on reviews that do not meet criteria
- Provide notification to facility of determination
- Facilitate member’s transfers within contract facilities for ongoing inpatient stays
- Complete documentation in electronic medical record and claims systems
- Initiate interdepartmental coordination to ensure quality and timely care for members
- Coordinate discharge planning to create member’s post-inpatient plan
- Interact with social worker, community agencies to identify alternate delivery of services
- Evaluate the need for case management and transition of care services following inpatient stay
- Coordinate transportation with contracted vendors following inpatient stay
Education / Experience / Other Requirements:
- Associate’s degree or higher from an accredited Nursing School required
Years of Experience:
- Previous UR/Discharge planning experience preferred
- Previous Medicaid/Medicare experience preferred
- InterQual criteria
- Strong knowledge of care management and care coordination
- Proficiency in computer and technology utilization required, including, but not limited to: care management software, data-analytics software, Microsoft Office Products (Outlook, Excel, Power Point, Word)