Tennessee Licensed Utilization Review Specialist

Job Summary

To support effective utilization management, the full-time Tennessee Licensed Utilization Review Specialist will conduct admission and concurrent reviews, manage appeals, and identify workflow improvement opportunities in a remote setting.

Key responsibilities

• Analyzes patient records to ensure compliance with admission and treatment standards set by insurers and regulatory agencies
• Reviews patient admissions and coordinates appeals, collaborating with clinical staff to resolve denial issues
• Monitors compliance with appeal timelines and prepares reports on quality improvement activities within the appeals department

Required qualifications

• Current state-issued RN license
• Minimum of five years of experience as a clinical nurse in an acute care setting
• At least five to seven years of experience in case management, discharge planning, and/or utilization review
• Knowledge of InterQual Level of Care Criteria and third-party payer regulations
• Ability to maintain confidentiality of patient data in compliance with HIPAA regulations