Utilization Review Nurse RN
Vetted Solutions · Randallstown, MD · Yesterday
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 denials, communicate with third-party payers, and document all review actions. The role involves monitoring utilization patterns, identifying potential denials, and collaborating with Care Managers, Physician Advisors, and other staff to resolve payer issues and optimize patient outcomes.
Responsibilities
- Perform initial, concurrent, and retrospective reviews of medical records for clinical, financial, and resource utilization assessment.
- Coordinate care to minimize delays and denials.
- Communicate with third-party payers regarding utilization and care decisions.
- Document all review actions and outcomes.
- Monitor utilization patterns and identify potential denials.
- Collaborate with Care Managers, Physician Advisors, and other staff to resolve payer issues.
- Support efficient care delivery and revenue cycle management.
Requirements
- Current RN license.
- Associate’s degree in nursing (BSN preferred).
- Minimum of 3 years of related experience.
Skills
- Strong clinical judgment.
- Excellent teamwork and communication skills.