Utilization Management Nurse

The Utilization Management Review Nurse is responsible for assisting in the development, planning, coordination, and administration of the Utilization Management activities. The Utilization Management Nurse conducts reviews to assure the appropriate levels of care and time of stay are delivered and promotes improved quality of care practices and cost containment efforts.

Job Specifications:

• Responsible for performing examinations of the cost efficiency and medical necessity of health care services while maintaining the quality of care
  • Reviews medical records to determine appropriateness and medical necessity of admission related to level of care
  • Applies appropriate criteria for level of care and medical necessity per payor and hospital policy
  • Identifies utilization issues and resolutions through clinical review
  • Collaborates with other members of the health care team to identify appropriate utilization of resources and length of stay for the patient
  • Conducts ongoing review of precertification requests for medical necessity
  • Monitors the activities of clinical and non-clinical staff related to appropriate care of patients as it relates to payor and hospital policy
  • Reviews appropriateness of extended stays as related to adherence to policy and need by documenting avoidable days
  • Coordinates with healthcare team related to patient’s discharge planning
• Evaluates effectiveness and appropriateness of department processes; develops objectives to achieve optimal outcomes
  • Participates in department review of metrics as related length of stay, avoidable days, and other applicable criteria
  • Assists with development of policies and workflows for department optimization
  • Performs analysis of related metrics to determine outcomes and assist with committee goals

Required Qualifications:

Education: Graduate of an accredited program in Nursing with a Bachelor's Degree; Experience may be accepted in lieu of degree requirement.

Licensure: Current MS RN licensure, compact license, or temporary permit for same (valid for 90 days only)

Experience: Four (4) years of acute care clinical hospital nursing experience.

Preferred Qualifications:

Experience: Quality, utilization or case management advanced knowledge and understanding of compliance principles.

About Memorial

Memorial Health System has been dedicated to healing, inspiring, and transforming the health of our community since 1946. With multiple hospital facilities, outpatient surgery locations and diagnostic centers, more than 100 Physician Clinics, and post-acute services including skilled nursing, you can find your fit at Memorial.

When you join our team, you join more than 5,000 individuals committed to exceptional care. We offer several of the region’s most comprehensive clinical programs and medical specialties unique to the Coast, including a Level III Neonatal ICU, state-designated Level II Trauma Center, Hyperbaric Oxygen Therapy, and Mississippi’s first nationally-certified Primary Stroke Center.

At Memorial, you are valued. We know that our increasingly diverse communities need healthcare professionals that reflect their different cultural backgrounds, perspectives, and values. We acknowledge the uniqueness of all individuals, their commonalities as well as differences, all of which have shaped their lives in meaningful ways.

The development of our team members is integral to the patient care we provide. Grow your skills, and grow with Memorial.

Memorial Health System is an equal opportunity employer and does not discriminate on the basis of any legally protected status or characteristic. Minority/Female/Sexual Orientation/Gender Identity/Disability/Veteran.