Utilization Review Nurse RN
About the Role
The Utilization Review Nurse RN conducts initial, concurrent, and retrospective reviews of medical records to assess clinical, financial, and resource utilization. They provide interventions to reduce avoidable delays and denials, interfacing with third-party payers by supplying relevant clinical information. The role involves applying utilization review criteria, documenting reviews, and coordinating with external reviewers, financial counselors, and patient access staff.
Additional duties include monitoring utilization patterns, identifying trends, collaborating with Care Managers, Social Workers, Physician Advisors, and administrative personnel to resolve payer issues, expedite appeals, and optimize patient outcomes. They also communicate discharge plans, assist with Medicare forms, and escalate cases when necessary.
Requirements
- Current RN license in MD (or Compact State)
- Associate’s Degree in Nursing required; BSN or higher preferred
- Minimum of 3 years of experience; 5+ years preferred