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Utilization Review RN

NH-United States-Dover Apply View Saved Jobs Job ID 3156925 Date posted 05/22/2021
Utilization Review RN-(3156925)


At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.

1.Evaluates the provision of care and the appropriate utilization of resources.
a.Reviews medical records for appropriateness of admission &/or continued stay using established criteria.
b.Communicates utilization issues to the appropriate individuals.
c.Serves as a resource to personnel in Patient Registration and Pre-Admission Services, & other staff as appropriate, regarding determination/ classification of the patient's admission status.
d.Discusses cases with the attending physicians; exploring strategies to optimize resource consumption.
e.Implements strategies to reduce lengths of stay when appropriate.
f.Participates in multidisciplinary discharge planning rounds.
g.Communicates with external case managers as appropriate.
h.Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
i.Actively conduct real time follow up on concurrent denials and pursue providing needed information to third party payors to authorize payment.

2.Demonstrates professionalism with managed care entities and processes.
.Keeps informed of changes in contractual relationships for all payer systems.
a.Provides requested information regarding patient care and services to external review and regulatory agencies.
b.Coordinates/ Performs all follow-up activities related to Medicare, other third-party payers, and hospital-negotiated contracts.
c.Communicates to patients, MDs, and other appropriate personnel changes in review findings resulting in level of care changes or findings consistent with termination/ denial of benefits.
d.Collaborates with managers & staff in the Patient Registration, Patient Accounts, and Medical Information Departments on issues of continued stay, denials, and related activities.
e.Assists medical staff in responding to appeals.
f.Provides information/ education to patients, family members, &/or patient representatives regarding the appeals process upon receipt of Medicare termination of benefits letters or commercial denial letters.
g.Informs CFO/VP of Finance and/or other management team members of situations which require notification or administrative action.
h.Assists medical record coders in clarification of medical clinical documentation issues related to DRG assignment.

3.Demonstrates excellence in leadership skills and professional performance .
.Maintains close communication with directors regarding utilization, quality of care, risk, and infection control issues.
a.Facilitates/ participates in ad hoc patient/ family conferences designed to gather information & resolve issues applicable to Utilization Review functions.
b.Participates in departmental and hospital committees, ad hoc committees, task forces and work groups.
c.Educates health team colleagues about utilization review, including the role of the case manager and the needs of the utilization reviewed population.
d.Participates in educational programs as requested &/or as appropriate.

4.Collects data pertinent to care management, utilization management, and performance improvement.
.Collects data related to clinical pathway variances.
a.Reports adverse drug reactions appropriately.
b.Reports issues related to infection control/ surveillance.
c.Collects data related to readmission's, avoidable days, attribution delays.
d.Tracks & trends over/ under utilization of resources through use of computerized database.
e.Reports data findings & any noted trends at UM Committee and to other appropriate individuals/ committees.


Experience Minimum Required
• 3-5 years of acute hospital experience.
• One year in specialty area or at least one year as Nurse Manager or at least one year in a Utilization Review or Quality Assurance position.

Experience Preferred/Desired
• 2+ years in a Utilization Review or Quality Assurance position.

Education Minimum Required
• Associates in Nursing

Education Preferred/Desired

Training Preferred/Desired
• Knowledge of Interqual and Milliman

Special Skills Minimum Required
• Strong clinical assessment skills and knowledge of medical standards of care.
• Knowledge of third party payer systems and levels of care.
• Extensive experience in dealing with medical staffs and medical staff committees.
• Ability to interrelate with physicians, nurses and other hospital personnel.
• Knowledge of government, voluntary and regulatory standards, requirements and guidelines for U.R. and Q.A.
•Knowledge of principles related to release of information and maintenance of confidentiality of data.
• Oral and written communication skills.
• Knowledge of basic infection control practice.
• Special Skills Preferred/Desired
• Applicable certification preferred

Licensure and/or Certifications Required
• RN

EEO StatementEqual Opportunity Employer/Protected Veterans/Individuals with Disabilities.
· The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Primary Location

:NH-Dover-WDH Broadway

Work Locations

WDH Broadway
121 Broadway


:Nurse Case Manager


:Wentworth-Douglass Hospital(WDH)


Standard Hours:24


:Day Job
Posted Shift Description:8 hour shifts, every other weekend.

Employee Status

Recruiting Department:WDH Care Coordination

Job Posting

:Jul 22, 2021


"The best thing about my job at Wentworth-Douglass is my co-workers; they are like family and I genuinely love to come to work!"

Environmental Services Staff


"I chose to come to WDH for many reasons: the location, the friendliness, and the welcoming environment I was surrounded with when I first entered. Walking into WDH you immediately feel at ease. It's like you aren't even in a hospital; it's clean, calming, and everyone is so friendly and welcoming. My department is a constant learning experience due to the need of radiology throughout the hospital. Anyone thinking of working here…DO IT! You won't regret it. If you're looking for an incredible job, full of wonderful experiences and great staff, don't hold yourself back. "

Registered Nurse


"When I began at WDH I was amazed at the technology and access to resources that are available to me which supports my day to day job function enabling me to be accurate, efficient and collect supportive data to make a difference for the future of the hospital, physicians, staff and our patients. Since being at WDH I have vastly built on my skill set as a Case Manager thanks to the expertise of the physician advisors, my manager and team of seasoned, expert Case Managers. WDH offers, encourages and supports professional growth with a strong team atmosphere. I have been encouraged to become involved in committees that promote positive change within my team. I feel I have a voice and can make a difference for the better.
My career as a Registered Nurse has become a lot clearer since joining my WDH team. I would say to anyone looking to advance his or her career, feel supported and belong to an awesome organization has a commitment to their community health; WDH is the place for you. "

Case Manager


"I chose to come to WDH because of its reputation. I had always heard such great things about the hospital and the staff. Coming here, I have found the teamwork is what I have enjoyed most; the staff have been so welcoming and have treated me like family. I love my job and the management is by far the best I have ever experienced. Anyone thinking of applying to WDH should definitely do it!"

ED Tech


"I did not know what I wanted to pursue as a career, but I knew I wanted to be in the medical field. I took a Phlebotomy course to get my foot in the door and got hired at WDH. Ten years later, I am still here and loving it every day. Not only do I love my coworkers, who have become my close friends, but I love the diversity of my job. Often times I feel people overlook what we do, but not only do we provide compassion and skill in our job to the patients, but we also get to see behind the scenes; working closely with the medical staff ensuring patients are getting accurate results. I feel rewarded at the end of everyday knowing that I have played a role in helping the patients get the proper treatment they need."



- Awards and Recognitions -

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Wentworth-Douglass Hospital has achieved Magnet® recognition, the nation’s highest honor for excellence in nursing, recognizing professionalism, teamwork and superiority in patient care.

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