Mercy Health

  • Utilization Review Nurse

    Requisition ID
    Position Type
    Full Time
    Days, Holidays, Weekends
    Care Mgt Facility Util Mgt
  • Overview

    Job Template Header


    We’re a Little Different


    Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.


    At Mercy, you’ll feel our supportive community every step of your day, especially the tough ones. We’re a team and love working that way. We have opportunities for nurses who are inspired to pioneer new models of care and want to transform the healthcare experience. Work with advanced technology and innovative procedures. Be state of the art, and never stop exploring. We’re expanding to help our communities grow, offering an exceptional opportunity to join our team.



    The Utilization Review Nurse is responsible for the development, implementation, coordination, and follow-up of projects related to Mercy Care Management. This includes the validation, assimilation, and integration of information derived from projects, focus studies, in network and out of network pre-certification, inpatient concurrent review and retrospective chart review. Performs related duties as assigned. Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.



    Coordinates and performs precertification, out of network precertification, inpatient concurrent review, retrospective review, reconsiderations and appeals. Performs each review process following the appropriate policy & procedure and within standard time frames.

    Collaborates with physicians and staff to provide medical management education and follow-up for precertifications, inpatient concurrent review, retrospective review and appeals. Collaborates with providers, as indicated, to provide them with medical management information.

    Performs telephone management with professional telephone etiquette when communicating with all parties.

    Collects and researches medical records and other forms of information to make effective and accurate non-medical decisions concerning all medical management review processes.

    Composes, types and mail standard letters of denials to health plan members, providers, and health plans member services referencing specific medical criteria utilized in the determination.

    Collaborates with physicians, facilities, health plan member services and claims staff as needed to obtain information regarding claim denials, their status, and actions taken that may affect their outcome.

    Develops and maintains a system for collecting, researching and coordinating information between Mercy Care Management, Mercy Care Management Medical Director(s), providers and outside agencies involving denials and appeals, and for recording and retrieval of that information.

    Implements and coordinates special medical management projects as directed. Maintains health plan benefit materials in reference manuals. Acts as a liaison to Provider Relations Department for contracted health plans.

    Maintains reports relating to the implementation, coordination, and follow-up of medical management review processes and special projects. Develops and maintains reporting tools and formats for denials and appeals, special projects and other departmental activities as requested.

    Screens and refers appropriate health plan members for full continuum case management, disease management, Nurse on Call or other care management strategies as applicable.

    Interacts with Data Management and appropriate Supervisor to provide system maintenance to the Referral and Case Management applications.

    Refers cases that do not meet medical criteria for precertification, inpatient concurrent review, and retrospective review to a Mercy Care Medical Director or Physician Advisor.

    Compiles statistical information related to all medical management review processes as requested.

    Performs retrospective chart review as indicated.

    Provides staff inservices for Mercy Care Management coworkers under the supervision of the Director(s)/Supervisor of Mercy Care Management.

    Maintains knowledge of and is compliant with current UM Plan and policies & procedures. Performs quality improvement activities and maintains current quality improvement document as directed.

    Maintains network provider listings and coordinates managed care contract reference information. Educates Mercy Care Management Department staff and Health Plan members and providers regarding providers available within the network under the supervision of the Director(s)/Supervisor.

    Observes Universal Precautions consistently. Wears proper Personal Protective Equipment when appropriate.

    Wears clothing and Health System identification badge consistent with dress code, and attends to personal hygiene to maintain a clean, well-groomed appearance.

    Meets Health System attendance standards. Perform other duties as assigned.



    Position Qualifications:

    • We require a nursing degree from an accredited school.
    • You’ll also need a current RN license in our state.
    • Basic life support training should be completed in 90 days with advanced training required at certain intervals.
    • Minimum of five years clinical experience.

    Other: Skills, Knowledge, and Abilities: Good communication and organizational skills, computer skills beneficial.

    Working Conditions, Mental and Physical Requirements: Knowledge of medical terminology, excellent oral and written communication skills, intermediate computer skills, capable of quickly learning other computer applications as needed, flexible, attentive to detail, and able to perform multiple tasks, good investigative, fact finding, and problem solving skills. Equipment Used: Computer, fax machine, copier, and other office equipment as needed.

    Preferred Education: BSN preferred.


    We’ll Support You at Work and Home


    Getting respect doesn’t come easy in healthcare. Modern Healthcare Magazine named us as a “top 100 places to work.” We go out of our way to help people feel welcomed. We offer day-one comprehensive health, vision and dental coverage, PTO, tuition reimbursement and employer-matched retirement funds to benefit-eligible co-workers, including those working 48 hours or more per pay period!



    What Makes a Good Match for Mercy


    Compassion and professionalism go hand-in-hand with us. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We’re also collaborative and are not afraid to do a little extra to deliver excellent care-that’s just part of our commitment. If that sounds like a fit for you as well, we encourage you to apply.

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