RN Utilization Review-Case Management-FT-1st shift

Responsibilities

• Conduct concurrent medical necessity reviews to ensure appropriate level-of-care determinations, regulatory compliance, and reimbursement integrity.
• Serve as a liaison between physicians, advanced practice providers, nursing, case management, revenue cycle, and payer organizations to facilitate accurate patient status assignment, timely authorization management, and denial prevention.
• Validate compliance with Medicare, commercial payer, and organizational requirements, including Inpatient Only (IPO) procedures, Two-Midnight Rule criteria, observation services, and medical necessity requirements.
• Collaborate with surgeons, physician assistants, nurse practitioners, hospitalists', and clinical staff to obtain clarifying documentation, facilitate timely order placement, and support appropriate status determinations.
• Serve as a resource for utilization management best practices and support broader utilization review functions as operational needs dictate.

Requirements

• Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) or Licensed Registered Nurse
• 2 years previous nursing experience
• Preferred: Bachelors Science Nursing or higher
• Preferred: ACM or CCM Certification

Skills

• Data entry skills
• Demonstrable skills with Google Docs, Google Sheets, Microsoft Suite and email applications