Utilization Nurse

The purpose of this position is to ensure patients receive high-quality, appropriate care through effective utilization management practices. The Utilization Nurse analyzes the effectiveness of treatments for each patient before, during, and after the delivery of care through daily chart reviews and collaboration with physicians and multidisciplinary stakeholders.

This role is responsible for managing emergency and non-emergency patient transfers and transportation requests via air, sea, and ground transportation. The position also supports the enhancement of patient care quality through innovative and cost-effective practices while promoting multidisciplinary integration to ensure continuity of care.

Duties Responsibilities: Conduct daily chart audits to ensure accuracy and quality of clinical documentation. Manage and monitor concurrent reviews to ensure patients receive appropriate, timely, and cost-effective care. Perform retrospective reviews following treatment to assess effectiveness and compliance with care standards.

Analyze medical records and patient information to ensure documentation accuracy and facilitate insurance claims processing. Evaluate treatment effectiveness before, during, and after patient care delivery. Coordinate and provide care that is safe, timely, effective, efficient, equitable, and patient-centered. Conduct medical necessity screenings and determine if clinical criteria are met.

Work closely with the financial team to minimize claim denials and support timely financial counseling. Coordinate hospital admissions and transfers into and out of Doctors Hospital Health System. Manage and coordinate patient transportation requests, including air, sea, and ground transfers, including EAGLE island transfers.

Respond promptly to all incoming emails and phone calls regarding patient transfers. Establish and maintain effective working relationships with partner transfer centers, referral sources, and healthcare providers. Maintain detailed documentation of admissions, transfers, conference calls, and related activities. Identify opportunities for improvement in patient treatment plans and resource utilization.

Conduct weekly multidisciplinary team meetings to support care coordination. Facilitate conference calls between providers to ensure continuity of care. Identify, resolve, and escalate service issues or process deviations when necessary. Notify physicians regarding insurance determinations and update patient records in the EMR.

Provide reports and analysis of utilization trends and resource impacts. Support financial services with timely quotations and optimization of coding and billing processes. Maintain a positive, professional, and collaborative approach in all communications. Provide exceptional customer service through effective and empathetic communication.

Adapt to change with a flexible and innovative approach. Meet departmental goals and quality standards as assigned.