Utilization Management RN - Revenue Integrity

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Overview
Yale School of Medicine advances education, discovery, and compassionate care through curiosity, innovation, and collaboration in an inclusive environment.

Reporting to the Associate Director of Specialty and Payer Management, the Clinical Reviewer is a non-patient-facing nursing professional who supports medical necessity reviews, authorization compliance, reimbursement optimization, and denial prevention. The role evaluates medical records, treatment plans, and payer policies to ensure services meet coverage criteria and regulatory standards.

The Clinical Reviewer serves as a liaison between providers, payers, and operational teams, translating clinical information into payer-specific documentation and authorization strategies. This administrative and analytical role requires strong clinical judgment, critical thinking, and knowledge of healthcare reimbursement and utilization management to reduce denials and support timely access to medically necessary care.

Key Responsibilities

• Clinical Review and Medical Necessity: Review documentation against payer policies and medical necessity criteria, identify gaps, and guide improvements to support authorization and reimbursement.
• Authorization and Payer Policies: Interpret payer requirements and advise providers and operational teams on compliance and discrepancies between authorized and performed services.
• Denials and Appeals: Prepare clinical summaries and medical necessity rationales for first-level, second-level, and external appeals; support provider preparation for peer-to-peer discussions; and identify ways to prevent recurring denials.
• Revenue Integrity: Identify and help resolve reimbursement risks related to authorization discrepancies and clinical documentation deficiencies.
• Provider Education and Collaboration: Serve as a clinical resource for providers and revenue cycle teams, communicating payer requirements and proactively addressing reimbursement barriers.

Required Skills and Abilities
1. Licensure as a Registered Nurse in the State of Connecticut or eligible for Connecticut licensure.

2. Experience in utilization management, case management, prior authorization, revenue cycle, specialty pharmacy, managed care, or related healthcare operations preferred.

3. Knowledge of medical necessity criteria, payer guidelines, and healthcare reimbursement processes.

4. Strong critical thinking and clinical assessment skills.

5. Proficiency with electronic health records and payer portal systems.

6. Excellent written and verbal communication skills.

Preferred Skills and Abilities
1. Certification such as:

• Certified Case Manager (CCM)

• Certified Professional Utilization Review (CPUR)

• Accredited Case Manager (ACM)

2. Experience with Medicare, Medicaid, and commercial payer policies.

3. Experience with specialty medications, infusion therapies, oncology, or high-cost treatment authorizations.

4. Experience using Epic and utilization management software platforms.

Principal Responsibilities

1. Performs physical assessments of patients, including triage duties and advises on treatment or course of action. 2. Identifies and evaluates nursing services problems and develops and implements appropriate programs and services, including assessing staffing needs and arranging coverage as needed. 3. Develops, implements, and manages nursing care plans in collaboration with physicians. 4. Instructs patients and families in proper treatment and advises patients on health maintenance and disease prevention. 5. Provides leadership, guidance, direction to clinical staff, and collaborates with nursing at all levels. 6. Determines standards for quality assurance and infection control procedures; trains staff in universal and isolation precautions in the area of infection control. 7. Performs diagnostic and therapeutic measures in collaboration with physicians. 8. Evaluates the quality and effectiveness of nursing practice and nursing services. 9. Records patients’ medical histories and symptoms, performs diagnostic tests and analyzes results, operates medical machinery, administers treatment and medications, and coordinates with patient follow-up and rehabilitation; assures all procedures for maintaining patient confidentiality are maintained per HIPAA guidelines. 10. May perform other duties as assigned. Required Education and Experience Bachelor’s Degree in Nursing and two years’ experience or an equivalent combination of education and experience.

Job Posting Date

11/05/2026

Job Category

Professional

Bargaining Unit

NON

Compensation Grade

Clinical & Research

Compensation Grade Profile

Registered Nurse 2 (24)

Salary Range

$68,000.00 - $120,500.00

Benefits

A general description of the benefits to be offered with this Managerial & Professional position is available at:

Yale Benefits

Time Type

Full time

Duration Type

Staff

Work Model

Remote

Background Check Requirements

All candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle, DOT certification, drug testing and credit checks based on the position description and job requirements. All offers are contingent upon the successful completion of the background check. For additional information on the background check requirements and process visit "Learn about background checks" under the Applicant Support Resources section of Careers on the It's Your Yale website.

Health Requirements

Certain positions have associated health requirements based on specific job responsibilities. These may include vaccinations, tests, or examinations, as required by law, regulation, or university policy.

Posting Disclaimer

Salary offers are determined by a candidate’s qualifications, experience, skills, and education in relation to the position requirements, along with the role’s grade profile and current internal and external market conditions.

The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the position. Employees will be assigned specific job-related duties through their hiring department.

The University is committed to basing judgments concerning the admission, education, and employment of individuals upon their qualifications and abilities and seeks to attract to its faculty, staff, and student body qualified persons from a broad range of backgrounds and perspectives. In accordance with this policy and as delineated by federal and Connecticut law, Yale does not discriminate in admissions, educational programs, or employment against any individual on account of that individual’s sex, sexual orientation, gender identity or expression, race, color, national or ethnic origin, religion, age, disability, status as a special disabled veteran, veteran of the Vietnam era or other covered veteran.

Inquiries concerning Yale's Policy Against Discrimination and Harassment may be referred to the Office of Institutional Equity and Accessibility (OIEA).

Note

Yale University is a tobacco-free campus.