Utilization Review Registered Nurse - 40 hours
Core
Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and compliance with reimbursement policy criteria.
Role type
Utilization Review Registered Nurse
Builds
Patient care coordination, utilization management, documentation, and reimbursement processes
Domain
Healthcare / Utilization Management
Required skills
Clinical assessment, critical thinking, decision-making, knowledge of medical necessity guidelines, knowledge of reimbursement guidelines
Preferred skills
Utilization Review or Care Management experience, knowledge of clinical documentation
Responsibilities
Reviews admissions and service requests for medical necessity and reimbursement compliance; Assists multidisciplinary teams with medical records, pre-certifications, and claim denials/appeals; Collaborates to assess and coordinate patient discharge planning; Monitors care delays to reduce length of stay and maximize reimbursement