Utilization Review RN

Job Summary

To support effective utilization management, the full-time remote Utilization Review RN will examine medical records, develop clinical reviews for authorization, and collaborate with interdisciplinary teams to optimize reimbursement and prevent payment denials.

Key responsibilities:

• Review and evaluate clinical information to support Utilization Management decisions based on medical documentation
• Facilitate communication with payors regarding medical necessity and coordinate the authorization process
• Advocate for patients and the hospital to optimize reimbursement and manage concurrent denials

Required qualifications:

• Current Registered Nurse license in the applicable state or multi-state license through the enhanced Nurse Licensure Compact (eNLC)
• Three years of healthcare clinical experience
• Knowledge of medical terminology and third-party payers
• Experience in Utilization Management or Medical Management for Medicare and/or Medicaid populations is preferred
• Bachelor's Degree in Nursing or currently enrolled in a BSN program with completion within three years of hire is preferred