Utilization Review Nurse RN
MEP Health · 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, aiming to reduce delays and payment denials. They interface with third-party payers by providing relevant clinical information, monitor utilization patterns, and coordinate with care managers and social workers to address potential denials and optimize patient outcomes.
Responsibilities
- Review medical records using utilization review criteria
- Enter reviews into software and document actions
- Coordinate with internal teams and payers to prevent denials
- Assist in communication and discharge planning with patients and families
- Identify opportunities for appeals and escalate cases appropriately
- Collaborate with physician advisors for unresolved cases
- Support expedited appeals
- Collaborate with multidisciplinary teams to improve patient care and resource management
Requirements
- Current RN license (Maryland preferred)
- Associate’s Degree in Nursing (BSN preferred)
- Minimum of 3 years related experience