Utilization Review Manager - Home Care ensures quality and level of care for patients are up to established standards and comply with federal, state, and local regulations. Investigates and resolves reports of inappropriate care. Being a Utilization Review Manager - Home Care may require a bachelor's degree. Typically reports to a head of a unit/department. To be a Utilization Review Manager - Home Care typically requires 4 to 7 years of related experience. Contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. (Copyright 2024 Salary.com)
To monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized. UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.
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