Utilization Review Nurse RN
CONSUMER DIRECTED SERVICES INC. · Randallstown, MD · 1 mo ago
On-siteHealthcareFull-time
About the role
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.
Responsibilities
- Apply utilization review criteria
- Document reviews in software
- Communicate with external reviewers and care teams
- Monitor utilization patterns
- Assist with discharge planning and Medicare forms
- Escalate unresolved cases to physician advisors for review
Qualifications
- Active RN license (Maryland preferred)
- Associate's degree in nursing (BSN or higher preferred)
- At least 3 years of related experience
Skills
- Strong clinical review abilities
- Strong communication abilities
- Strong coordination abilities
- Strong 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.