Newport Medical Center
Utilization Nurse
Newport
,
TN
Full Time
Job Summary
The Utilization Review Nurse - LPN coordinates key components of the facility's utilization management program, including admission reviews, status validations, and documentation support. This role performs third-party criteria assessments to determine medical necessity, assists with denial and appeal activities, and supports efforts to reduce unnecessary readmissions. The Utilization Review Nurse - LPN may also contribute to quality assurance and resource management initiatives.
Essential Functions
The Utilization Review Nurse - LPN coordinates key components of the facility's utilization management program, including admission reviews, status validations, and documentation support. This role performs third-party criteria assessments to determine medical necessity, assists with denial and appeal activities, and supports efforts to reduce unnecessary readmissions. The Utilization Review Nurse - LPN may also contribute to quality assurance and resource management initiatives.
Essential Functions
- Reviews medical records to determine medical necessity for admission using established third-party criteria (e.g., MCG, InterQual).
- Validates admission status and identifies potential discrepancies in patient placement.
- Initiates provider queries to clarify documentation and support appropriate utilization.
- Participates in interdisciplinary team meetings to discuss patient care plans and discharge readiness.
- Supports the implementation of process improvement initiatives related to utilization management and readmission reduction.
- Escalates complex or unresolved cases to appropriate leadership or physician advisors.
- Maintains compliance with internal policies, payer requirements, and regulatory guidelines.
- Protects patient privacy and ensures security of Protected Health Information (PHI).
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- 2-4 years of experience in a hospital or nursing home setting required
- Strong written and oral communication skills.
- Demonstrates empathy, compassion, and professionalism in patient interactions.
- Proficient in utilization management processes, criteria sets, and managed care standards.
- Knowledge of healthcare informatics and Electronic Health Records (EHR) systems.
- Sound problem-solving and critical thinking skills.
- Excellent organizational and time management skills to manage competing priorities.
- LPN - Licensed Practical Nurse - State Licensure required or
- LVN - Licensed Vocational Nurse required