Trauma Nurse Core Course (TNNC) within 12 months of hire required.
Current BLS certificate upon hire and maintain current.
Current and valid state RN License.
Non-OB facilities: NRP certificate 90 days upon hire and maintain current.
In Paramedic Base Station ED: MICN within 12 months of hire and maintain current.
Current ACLS certificate 30 days upon hire and maintain current.
Current PALS certificate and/or ENPC 30 days upon hire and maintain current.
Minimum of one year experience as a staff nurse RN in an acute care hospital setting;
Basic Arrythmia Interpretation within 30 days of hire.
EDAP certified facilities: Completion of emergency pediatric course 1 and 2 within 6 months of hire.

SmartExplore AI is experimental.

New, Posted 18 hours ago

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Travel Nurse RN - Utilization Review - $2,459 per week in Camden, ME

TravelNurseSource

Camden, ME 04843

$2,459/wk

~ 26 min Onsite

Ensure that utilization review practices comply with regulatory standards, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and other state or federal regulations.
Communicate with healthcare teams to discuss any discrepancies or concerns regarding the utilization of resources, care plans, or treatment goals.
Stay current on the latest healthcare policies, clinical guidelines, and best practices for utilization management.
Provide detailed, evidence-based rationales for medical necessity determinations and collaborate with the healthcare team to ensure compliance with UR protocols.
Educate staff and providers on the importance of utilization review processes, medical necessity criteria, and compliance with payer requirements.
Review patient medical records, treatment plans, and clinical data to assess the appropriateness of the care being provided and the necessity for continued hospitalization or services.
Resolve any issues related to denied claims or requests for additional documentation to ensure that services are covered by insurance providers.
Maintain up-to-date knowledge of healthcare regulations, coding guidelines (ICD-10, CPT), and payer-specific policies to ensure accurate documentation and compliance.
Provide recommendations or alternative care options to improve patient outcomes and optimize resource utilization.
Prepare reports on utilization metrics, including patterns in hospital admissions, readmissions, and discharge delays, for management and leadership review.
Participate in continuing education and training programs related to UR, case management, or quality improvement initiatives.
Document findings from utilization reviews in the appropriate systems and ensure accurate record-keeping for insurance purposes and quality improvement efforts.
Assess the medical necessity of procedures, tests, and treatments to ensure they align with established guidelines and criteria, such as those from the InterQual or Milliman Care Guidelines.
Collaborate with physicians, case managers, and other healthcare professionals to ensure that patient care plans are appropriate and cost-effective.
Provide feedback to clinicians and healthcare teams regarding any areas for improvement in care planning or resource utilization.
Monitor patient length of stay (LOS) to identify potential delays in discharge and ensure that patients are not staying in the hospital longer than necessary.
Assist with audits to evaluate the efficiency and accuracy of utilization management processes, making improvements where necessary.
Registered Nurse (RN) – Utilization Review
Identify potential barriers to discharge and collaborate with the interdisciplinary team to address these issues and facilitate a timely discharge.
Evaluate whether the care provided is appropriate, efficient, and meets the standards of care based on clinical evidence.
Recommend the appropriate level of care (e.g., inpatient, outpatient, skilled nursing facility) based on clinical findings and guidelines.
Work with case management teams to develop appropriate discharge plans, ensuring that the patient is ready for discharge and has the necessary resources and follow-up care.
Perform retrospective and concurrent review of patient cases to determine if the level of care aligns with guidelines and if resources are being utilized efficiently.
Work closely with insurance companies, managed care organizations, and government payers (e.g., Medicare, Medicaid) to review cases for coverage, authorization, and reimbursement.
Submit necessary documentation and justification to insurance companies to support medical necessity determinations and secure prior authorization for treatments, procedures, or extended hospital stays.

SmartExplore AI is experimental.

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Director of Nursing, DON

Windward Gardens

Camden, ME 04843

$125,000/yr

$10,000 bonus

~ 26 min OnsiteEducation AssistanceHealth InsurancePaid Time OffRetirement Benefit

Must be a graduate of an accredited school of nursing, college or university with a current Registered Nurse license by the State Board of Nursing
At least 2 years of prior clinical experience is required.
At least 1 year of nurse leadership experience in long-term care is required.
Must have knowledge of the MDS process, state nurse practice act, and state/federal regulations.
On-call availability is required.

SmartExplore AI is experimental.

New, Posted 7 hours ago

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