Utilization Review Nurse RN
Role Overview
The Utilization Review Nurse RN conducts initial, concurrent, and retrospective reviews of medical records to assess clinical, financial, and resource utilization. They facilitate coordination to reduce avoidable delays and denials of payment, interfacing with third-party payers by providing relevant clinical information. This role involves monitoring utilization patterns, identifying trends, and collaborating with care managers, social workers, and physician advisors to resolve payer issues and expedite appeals. The nurse assists in communicating discharge plans and Medicare forms to patients and families, aiming to optimize patient outcomes, decrease length of stay, and prevent delays or denials. Responsibilities include documenting review actions, managing cases with unresolved issues, and escalating cases requiring physician review.
Qualifications & Skills
- Current Maryland RN license or eligibility
- Associate's Degree in Nursing required; BSN preferred
- Minimum of 3 years of relevant experience
Key Duties
- Perform utilization reviews using established criteria
- Coordinate with care teams to ensure efficient patient care
- Manage denials and facilitate appeals processes
- Communicate effectively with payers, providers, and patients
- Document all review activities accurately in software systems
- Identify opportunities for process improvement and resolution of payer issues