Utilization Management RN

About the role

The Utilization Management Registered Nurse (UM RN) will be responsible for ensuring the efficient and effective use of healthcare resources while promoting quality patient care. Working in collaboration with Physician Advisors, Financial Services, Compliance, Denials Management, Patient Access, Clinical Documentation Integrity, Billing, and Revenue Cycle, the UM RN plays an essential role in the financial health of the institution, navigating the complexities of patient care and resource utilization management, and education.

Responsibilities

• Coordination with Healthcare Teams: Work closely with other healthcare professionals, patients, and payers to assess, plan, coordinate, monitor, and evaluate the delivery of healthcare services and appropriate levels of care.
• Medical Records Review: Examine patient medical records to ensure the necessity and appropriateness of care provided.
• Utilization Review: Conduct thorough utilization reviews, applying evidence-based criteria and guidelines to optimize patient outcomes and manage healthcare costs.
• Denials and Appeals Management: Address and manage denials by reviewing cases, gathering relevant data, and preparing appeals. Collaborate with physician advisors to ensure clinically sound and persuasive appeals.
• Physician