Utilization Review Nurse

Responsibilities and Duties:

• Conduct concurrent, retrospective, and pre-admission reviews to determine medical necessity and level of care.
• Evaluate clinical documentation to ensure appropriate utilization of services according to established criteria (e.g., InterQual, MCG).
• Collaborate with physicians, case managers, and insurance companies to coordinate care and obtain authorization for services.
• Identify and report potential delays in care, underutilization, or overutilization of services.
• Participate in denial management by preparing and submitting clinical appeals when necessary.
• Maintain accurate and timely documentation of utilization review activities in the electronic medical record (EMR) and UR tracking systems.
• Ensure compliance with CMS, state regulations, Joint Commission standards, and payer requirements.
• Provide education and guidance to clinical staff regarding documentation requirements and utilization criteria.
• Support quality improvement initiatives related to care efficiency, patient outcomes, and cost containment.

Job Requirements:

• Minimum 2-3 years of clinical nursing experience (medical-surgical or case management)
• Current, active Registered Nurse (RN) licensure
• Prior experience in UR, CM, or health insurance review highly desirable
• Strong written and verbal skills, proficient computer skills
• Excellent clinical judgement, critical thinking, and communication skills
• Strong understanding of medical necessity criteria, managed care principles, and reimbursement methodologies.