Hallmark Health System
The Utilization Review RN is responsible for the leveling of all Commercial Patients and communicating level of care based on contracts to the specified payer. The Utilization Review RN ensures medical necessity of hospitalization and treatment in accordance with hospital and third party payor guidelines and criteria. This position ensures appropriate utilization of hospital resources and works with other physicians and health care team members to manage care in a cost-effective and efficient manner.
Graduate of an Accredited School of Nursing required; BSN strongly preferred. Registration and current Massachusetts RN Licensure in good standing required. Candidates who do not have a Bachelor's Degree in Nursing may be considered, but must be enrolled in a Baccalaureate program within 1 year of hire. Professional certification highly encouraged. 2 years of experience in a Medical/Surgical setting and one year of experience in discharge planning/utilization management preferred. Knowledge of InterQual criteria required. Familiarity with Medicare, Medicaid, managed care, and other 3rd party payor expectations.