Utilization Review Nurse RN

The Utilization Review Nurse RN is responsible for conducting initial, concurrent, and retrospective chart reviews to assess clinical, financial, and resource utilization. They provide intervention and coordination to reduce avoidable delays and denials of payment by interfacing with third-party payers and supplying relevant clinical information. Key duties include applying utilization review criteria, documenting reviews in software, communicating with external reviewers and care teams, and monitoring utilization patterns. They assist with discharge planning, Medicare forms, and escalate unresolved cases to physician advisors for review. Qualifications: Active RN license (Maryland preferred), associate's degree in nursing (BSN or higher preferred), with at least 3 years of related experience. Skills: Strong clinical review, communication, coordination, and documentation abilities to optimize patient outcomes, manage denials, and facilitate appeals. This role emphasizes collaboration with care managers, physicians, and administrative staff to ensure efficient care delivery and compliance with payor requirements.