Utilization Review Nurse RN
Northshore Home Health Care · Randallstown, MD · 1 wk ago
HealthcareFull-time
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 coordinate care to reduce delays and prevent payment denials by providing relevant clinical information to third-party payers. 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 optimal patient outcomes. They assist with discharge communications and maintain documentation of actions taken to avoid unnecessary delays and denials.
Responsibilities
- Review medical records using utilization review criteria
- Interface with external reviewers, financial counselors, and payers
- Monitor utilization trends and denials
- Coordinate follow-up actions with Care Managers and social services
- Assist with discharge notices and documentation
- Identify opportunities for expedited appeals and resolve payer issues
- Refer cases to Physician Advisors when criteria are not met
Qualifications & Skills
- Current RN license (Maryland or eligible)
- Associate's Degree in Nursing (BSN preferred)
- Minimum of 3 years of relevant experience