Utilization Review Nurse - DC Licensed

Job Summary

A company is looking for a Utilization Review Nurse (Remote) to conduct clinical chart reviews and ensure compliance with medical necessity and reimbursement policies.

Key Responsibilities

• Conduct timely clinical chart reviews and apply appropriate clinical criteria according to protocols and payer agreements
• Review admission service requests for medical necessity and compliance with reimbursement policies
• Serve as a resource for education and communication regarding utilization review and performance improvement

Required Qualifications

• 3-5 years of experience in acute care case management or utilization management activities
• Knowledge of InterQual/Milliman and CMS guidelines
• Current knowledge or certification in utilization management/case management
• RN-BSN preferred, RN-AA acceptable; DC or MD license required based on assignment
• Experience in Utilization Review and Case Management Discharge planning