Utilization Review (RN) - Part Time (28 hours/week)
Core
Evaluates medical necessity, appropriateness, and efficiency of healthcare services using MCG criteria to ensure CMS compliance and prevent avoidable denials.
Role type
Utilization Review Registered Nurse (RN)
Builds
Insurance pre-authorizations and safe care transitions
Domain
Healthcare administration and utilization management
Required skills
Acute care nursing experience, MCG/InterQual guidelines knowledge, CMS Conditions of Participation familiarity, commercial billing requirements knowledge
Preferred skills
BSN, Cerner EHR experience, hospital case management experience
Responsibilities
Facilitate timely insurance pre-authorizations, confirm medical necessity, investigate denials and revenue loss, monitor length of stay and avoidable days, report trends to Utilization Review Committee
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