Utilization Review Technician conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Being a Utilization Review Technician reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Additionally, Utilization Review Technician consults with nurses and physicians as needed. Position is non-RN. May require an associate degree or its equivalent. Typically reports to a supervisor. May require Registered Health Information Technician (RHIT). The Utilization Review Technician gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Utilization Review Technician typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Job Summary |
The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. He/she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations/guidelines/criteria related to UM. The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital’s UR Committee. He/she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program.
Education |
Education Type |
Program of Study |
Required/Preferred |
High School Diploma |
N/A |
Required |
Associate’s degree |
Nursing |
Required |
Bachelor’s degree |
Nursing |
Preferred |
Experience |
Number of Years |
Type of Experience |
Required/Preferred |
5 Years |
Clinical nursing |
Required |
1 Year |
Inpatient Utilization Review |
Preferred |
Certification & Licensures |
Certification/Licensure Type |
Required/Preferred |
Registered Nurse (RN), with Authorization to Practice in the State of Texas |
Required |
ACM (Accredited Case Manager) through ACMA |
Preferred |
CCM (Certified Case Manager) through CCMC |
Preferred |
*Must obtain within ninety (90) days of hire
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