Utilization Review Nurse RN - PRN

Key Responsibilities

• Perform initial, concurrent, and retrospective utilization reviews using established clinical criteria to evaluate medical necessity, level of care, and resource utilization.
• Review medical records for clinical, financial, and utilization management information and accurately document findings in the designated utilization management software.
• Communicate with third-party payers to obtain certifications, authorizations, and continued stay approvals by providing relevant clinical information.
• Monitor utilization trends, identify potential or actual denials, and implement interventions to reduce avoidable delays and reimbursement issues.
• Collaborate with Care Managers, Social Workers, physicians, financial counselors, and patient access staff to coordinate patient care and support appropriate discharge planning.
• Assist Care Managers in communicating denied hospital days and issuing required Medicare notices, including the Hospital-Issued Notice of Noncoverage (HINN) and Detailed Notice of Discharge, to patients and families when appropriate.
• Coordinate with Care Management to promote efficient patient throughput, optimize length of stay, and improve patient outcomes.
• Escalate cases that do not meet medical necessity criteria to the Physician Advisor for review and recommendations.
• Partner with the Physician Advisor and interdisciplinary team to facilitate expedited appeals and resolve payer-related issues.
• Maintain compliance with organizational policies, payer requirements, regulatory standards, and documentation guidelines.
• Identify opportunities for process improvement within utilization management and contribute to quality initiatives.

Qualifications

• Active Registered Nurse (RN) license in good standing.
• Knowledge of utilization review, medical necessity criteria, reimbursement processes, and payer regulations.
• Strong clinical assessment and critical thinking skills.
• Excellent communication, documentation, and organizational skills.
• Ability to work collaboratively with interdisciplinary teams and external payer representatives.
• Proficiency with electronic health records (EHR) and utilization management software.
• Previous experience in Utilization Management, Case Management, or Care Coordination.
• Experience using InterQual®, MCG®, or other evidence-based utilization review criteria.
• Certification in Case Management (CCM), Utilization Review (CPUR), or a related specialty preferred.