Utilization Review RN

Are you a skilled and experienced Utilization Review Specialist looking for a rewarding opportunity to impact patient care and optimize hospital resources? Join our dynamic team and play a crucial role in ensuring appropriate admission status and continued stay authorization for our patients. This position offers the flexibility to work remotely with proven Utilization Review experience. Medical Coding experience is a plus!

As our Utilization Review RN, you will be responsible for conducting comprehensive reviews of medical records using evidence-based guidelines and critical thinking to determine the medical necessity of inpatient services. You will collaborate closely with attending physicians, consultants, Care Coordination staff, and Concurrent Denial RNs to prevent denials and optimize patient outcomes.

Key Responsibilities:

• Perform admission, concurrent, and post-discharge reviews to ensure adherence to Utilization Review guidelines and appropriate patient status determination.
• Collaborate with Patient Access to verify payer sources and obtain necessary inpatient authorizations from insurance providers.
• Identify and address deficiencies in patient status orders, communicating effectively with providers to ensure accuracy.
• Engage with Denials RNs and revenue cycle vendors to implement denial prevention strategies.
• Ensure compliance with hospital policies, regulatory agencies (e.g., The Joint Commission), and payer-defined criteria.
• Facilitate Peer-to-Peer reviews between hospital providers and insurance providers, when necessary.
• Communicate review outcomes and necessary notifications to physicians, payers, Care Coordinators, and other stakeholders.
• Engage the second level physician reviewer, internal or external, as indicated to support the appropriate status.

• Graduate of an accredited school of nursing
• Utilization Review experience required
• Minimum two (2) years of acute hospital clinical  experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• Coding experience preferred