Nurse utilization review specialist iii

At UK St. Claire, our staff is our greatest asset in the mission to create a healthier and more prosperous population. We strive to foster the talent and potential of our employees and prioritize safe working conditions and equal compensation rates to ensure that continual growth is possible. UKSC is a nurturing workplace for all healthcare professionals. We invite you to explore our current job openings and see if our opportunities could be the right fit for you.

Job Description:

Job Summary

Responsible for evaluating all newly admitted patients to ensure appropriate hospitalization, documentation accuracy, order entry, and proper designation of level of care. Serves as a key liaison between physicians, nursing staff and weekend social workers, patients, insurance providers, and government payers to ensure quality patient care and proper reimbursement. Collaborates on discharge planning and coordinate post-acute services such as home health and durable medical equipment.

Essential Functions

• Assesses all newly admitted patients for appropriate hospitalization, accurate documentation, proper order entry, and correct level of care designation.
• Conducts daily reviews for patients whose payer requires continued review, ensuring medical necessity is consistently documented and communicated.
• Collaborates with physicians regarding patient status, level of care, and necessary documentation to meet medical necessity and payer requirements.
• Serves as a liaison with insurance companies, Medicare, and Medicaid to provide timely updates, submit required medical information, and secure authorizations for continued hospitalization.
• Works closely with nursing staff and weekend social workers to assess patient needs and coordinate home health services, durable medical equipment (DME), and other post-discharge resources.
• Partners with the healthcare team to facilitate effective communication, ensure continuity of care, and support safe and efficient patient transitions.
• Performs other duties as assigned.

Education Requirement:

Associate Degree - ADN

Experience Requirement:

3-5 Years. An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted.

Certifications & Licensures:

Nursing License

Working Conditions

A. Lifting, pushing, and/or pulling objects up to 50lbs:1. Never (< 10% of the time)
B. Lifting, pushing, and/or pulling objects over 50lbs:1. Never
C. Standing or walking with objects up to 10lbs:3. Intermittent (10% - 50% of the time)
D. Standing or walking with objects up to 25lbs:1. Never (< 10% of the time)
E. Sitting at the computer workstation for extended periods:3. Intermittent (100% of the time)
F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials:2. Occasional (< 10% of the time)
G. Repetitive motion:3. Intermittent (100% of the time)
H. Working at heights above 4 feet:1. Never
I. Working in confined spaces:1. Never
J. Risk of injuries from use of equipment on the job:2. Occasional (< 10% of the time)
K. Job-related travel:2. Occasional (< 10% of the time)
L. Loud noises:1. Never
M. Temperature extremes:1. Never
N. Hazardous chemicals and fumes including waste:1. Never (< 10% of the time)
O. Radiation:1. Never
P. Burns:1. Never
Q. Cuts/Punctures:1. Never (< 10% of the time)
R. Bloodborne/airborne pathogens:2. Occasional (< 10% of the time)
S. Recombinant DNA or viral vectors:1. Never
T. Combative/violent people:1. Never
U. Animal handling (including carcasses):1. Never
V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A

Physical Demands

This position requires sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); and intermittent standing or walking with objects weighing up to 10 pounds.