Nurse Utilization Review Specialist III

Responsible for evaluating all newly admitted patients to ensure appropriate hospitalization, documentation accuracy, order entry, and proper designation of level of care. Serves as a key liaison between physicians, nursing staff and weekend social workers, patients, insurance providers, and government payers to ensure quality patient care and proper reimbursement. Collaborates on discharge planning and coordinates post-acute services such as home health and durable medical equipment. Department: Review. Shift: Day (United States of America). Address: 800 Rose Street, Lexington, Kentucky. Physical demands: sitting at a computer workstation for extended periods, repetitive motions (such as typing), and intermittent standing or walking with objects weighing up to 10 pounds.

Responsibilities

Assesses all newly admitted patients for appropriate hospitalization, accurate documentation, proper order entry, and correct level of care designation; Conducts daily reviews for patients whose payer requires continued review, ensuring medical necessity is consistently documented and communicated; Collaborates with physicians regarding patient status, level of care, and necessary documentation to meet medical necessity and payer requirements; Serves as a liaison with insurance companies, Medicare, and Medicaid to provide timely updates, submit required medical information, and secure authorizations for continued hospitalization; Works closely with nursing staff and weekend social workers to assess patient needs and coordinate home health services, durable medical equipment (DME), and other post-discharge resources; Partners with the healthcare team to facilitate effective communication, ensure continuity of care, and support safe and efficient patient transitions; Performs other duties as assigned

Requirements

Associate Degree (ADN); 3-5 years of paid experience in the same related field; Nursing License