Utilization Review Nurse RN
Fairview Hospital / Cleveland Clinic · Randallstown, MD · 1 wk ago
HealthcareFull-time
About the Role
The Utilization Review Nurse RN conducts initial, concurrent, and retrospective chart reviews to assess clinical, financial, and resource utilization. The goal is to reduce avoidable delays and payment denials by communicating with external reviewers, financial counselors, and payers to provide relevant clinical information and support certification activities. The nurse monitors utilization patterns, identifies potential denials, and collaborates with Care Managers, Social Workers, and Physician Advisors to resolve issues, expedite appeals, and ensure efficient patient outcomes.
Responsibilities
- Review medical records using utilization criteria
- Interface with payers and healthcare teams
- Coordinate care to prevent delays and denials
- Assist with appeals and documentation
- Identify utilization trends and communicate findings
- Support patient discharge processes and payer interactions
- Document actions taken to resolve utilization issues
- Collaborate to minimize patient length of stay
- Manage payer disputes
Requirements
- Current Registered Nurse license (Maryland or eligible)
- Associate’s Degree in Nursing (BSN preferred)
- Minimum of 3 years of related experience