Continuous Utilization Review Nurse M116

CLASS SUMMARY
The Utilization Review Nurse works under administrative direction and is
responsible for performing reviews of medical and/or economic service
utilization.  This position is governed by state and federal laws and agency
policy.


EXAMPLES OF WORK
1.  Performs utilization review to verify level of care, frequency of
  utilization, frequency of placement into appropriate care or service area,
  and appropriateness of provider facilities and operations.  Determines
  action to be taken.

2.  Reviews completed staff survey documentation, complaint investigation
  reports, and/or provider detail and exception reports to determine
  accuracy and compliance with regulations.  Reviews applications and
  recommends approval/denial.

3.  Performs quality review surveys to determine accuracy of surveys and/or
  investigations and application of regulations, or conducts surveys to
  review equipment used and/or services provided in hospitals, physician's
  offices, clinics, or homes.  May respond to requests to conduct follow-up
  surveys of compliance-troubled facilities, clinics, and/or in-home care
  agencies.

4.  Provides technical assistance to other units and divisions, caregivers,
  and providers on service availability and requirements, attends in-service
  training and continuing education classes, or provides training to staff
  and other medical professionals.

5.  Researches regulations and prepares reports, reviews and recommends
  changes in policies and procedures, assists with policy development, and
  may update policies and procedures manuals.

6.  Provides direction and instruction to a small nursing and administrative
  support staff by providing training, approving leave, and prioritizing
  work.

7.  Performs related responsibilities as required or assigned.

WORKING RELATIONSHIPS
The Utilization Review Nurse has regular contact with agency personnel,
physicians, nursing specialists, hospital and/or nursing home officials, and
state and federal agency health professionals.  Occasional contact with agency
management and their staffs and elected officials and their staffs may be
required.

SPECIAL JOB DIMENSIONS
Little to occasional in-state travel may be required.

KNOWLEDGES, ABILITIES, AND SKILLS
Knowledge of state and federal regulations governing medical/economic services
  utilization.
Knowledge of the principles, practices, and theories of nursing.
Knowledge of case management, health records review, and monitoring procedures.
Ability to plan, organize, and direct the work of others.
Ability to prepare, present, and review oral and written information and
  detailed reports.
Ability to interpret and apply state and federal laws, regulations, and
  policies governing utilization review.
Ability to review and verify utilization compliance and determine corrective 
  action.

MINIMUM QUALIFICATIONS
Licensed by the Arkansas State Board of Nursing as a Registered Nurse as
established by Acts 432 of 1971, 613 of 1979, and 19 of 1981; plus two years'
experience in nursing services, including one year in case management
activities.

Other job related education and/or experience may be substituted for all or
part of these basic requirements upon approval of the Qualifications Review
Committee.