Registered Nurse (RN) - Utilization Review - PRN Days

The Utilization Management Nurse (UM) Coordinator plays a vital role in reviewing medical necessity and determining appropriate levels of care through 24/7 clinical assessments. Responsibilities include performing utilization reviews for new admissions, observation cases, and concurrent care, utilizing clinical guidelines and collaborating with physicians and payers to secure timely authorizations. They ensure documentation in systems like EPIC, monitor post-discharge accounts for discrepancies, and communicate effectively to resolve authorization issues before billing. Key duties involve assessing patient needs using established criteria, ensuring compliance with payer and regulatory requirements, advocating for patients, and supporting performance improvement initiatives. The role requires a minimum of 3 years of clinical experience, strong clinical knowledge, and proficiency in clinical review tools such as mcg Indicia. Additional skills include excellent communication, documentation accuracy, ability to manage complex cases, and a collaborative approach to resolve denials and facilitate safe patient transitions.