Utilization Nurse

Community Health Systems • Newport, TN • 5h ago

Job Summary

The Utilization Review Nurse - LPN coordinates key components of the facility's utilization management program, including admission reviews, status validations, and documentation support. This role performs third-party criteria assessments to determine medical necessity, assists with denial and appeal activities, and supports efforts to reduce unnecessary readmissions. The Utilization Review Nurse - LPN may also contribute to quality assurance and resource management initiatives.

Essential Functions

Reviews medical records to determine medical necessity for admission using established third-party criteria (e.g., MCG, InterQual).

Validates admission status and identifies potential discrepancies in patient placement.

Initiates provider queries to clarify documentation and support appropriate utilization.

Participates in interdisciplinary team meetings to discuss patient care plans and discharge readiness.

Supports the implementation of process improvement initiatives related to utilization management and readmission reduction.

Escalates complex or unresolved cases to appropriate leadership or physician advisors.

Maintains compliance with internal policies, payer requirements, and regulatory guidelines.

Protects patient privacy and ensures security of Protected Health Information (PHI).

Performs other duties as assigned.

Maintains regular and reliable attendance.

Complies with all policies and standards.

Qualifications

2-4 years of experience in a hospital or nursing home setting required

Knowledge, Skills and Abilities

Strong written and oral communication skills.

Demonstrates empathy, compassion, and professionalism in patient interactions.

Proficient in utilization management processes, criteria sets, and managed care standards.

Knowledge of healthcare informatics and Electronic Health Records (EHR) systems.

Sound problem-solving and critical thinking skills.

Excellent organizational and time management skills to manage competing priorities.

Licenses and Certifications

LPN - Licensed Practical Nurse - State Licensure required or

LVN - Licensed Vocational Nurse required

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.

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