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Hines · 10 hours ago

Utilization Review Registered Nurse

Rockford, Illinois

Full-time

Hybrid

Mid, Senior Level

3+ years exp

Hines is a nationwide, independent leader in personalized managed health care, focused on comprehensive services with program excellence. The Utilization Review Registered Nurse will utilize clinical knowledge to assess patient conditions and determine the appropriateness of treatments based on established guidelines.

Health CareInsurance

Responsibilities

Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to the clinical areas addressed in most initial clinical reviews

Demonstrates ability to assess a patient’s current medical status, including complications and untoward events, which may require additional intervention. Provides certification of medical, disability and workers compensation cases

Demonstrates a thorough understanding of criteria sets and their limitations including when a second level review is required

Evaluates appropriateness of current plan of care

Assesses aftercare needs, implements discharge planning and/or case management referral in a timely manner

Maintains knowledge of current advances and trends in medical care

Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions. Able to attain and maintain the minimal quality assurance performance standards

Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures

Performs onsite evaluations as needed or requested

Additional responsibilities as assigned

Communicates with hospital staff, physicians, other providers and Hines customer contacts in a competent, calm, effective and professional manner

Effectively communicates the need to refer to a higher-level review for questionable plans of treatment

Provides written documentation concerning the clinical information obtained regarding the patient’s status, benefit and claim concerns, and validation of criteria

Communicates knowledge of policies and procedures, URAC guidelines, disability and workers compensation regulations, state and federal requirements, and standards of practice

Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism

Creative and assertive

Qualification

Registered Nurse LicenseUR Nurse OrientationAcute Clinical PracticeManaged Care ExperienceCustomer Service Orientation

Required

Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed

Successful completion of UR nurse orientation program

Minimum of 3 years recent acute clinical practice required

Customer service oriented

Preferred

5 years of recent acute clinical practice preferred

Managed care, disability or workers compensation experience helpful but not mandatory

Benefits

Medical

Dental

Vision

Long-term care

Short-term disability

Long-term disability

Company paid and voluntary life insurance

Critical Illness

Accident insurance

Flexible spending

401k plan with company match, fully vested after 1 year

Paid Holidays

Company

Hines

Hines, a member of the Global Excel family, has built it's reputation as an industry leader, founded on over three decades of innovative and professional healthcare excellence.

Founded in 1987

Elgin, Illinois, USA

201-500 employees