Utilization Review RN

Are you a skilled and experiencedUtilization Review Specialistlooking for a rewarding opportunity to impact patient care and optimize hospital resources Join our dynamic team and play a crucial role in ensuring appropriateadmission statusandcontinued stay authorizationfor our patients. This position offers the flexibility to workremotelywith provenUtilization Reviewexperience.Medical Codingexperience is a plus!

As ourUtilization Review RN you will be responsible for conducting comprehensive reviews ofmedical recordsusing 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 andConcurrent Denial RNsto prevent denials and optimize patient outcomes.

Key Responsibilities:

• Performadmissionconcurrent andpost-discharge reviewsto ensure adherence toUtilization Reviewguidelines and appropriatepatient status determination.
• Collaborate withPatient Accessto verify payer sources and obtain necessaryinpatient authorizationsfrom insurance providers.
• Identify and address deficiencies in patient status orders communicating effectively with providers to ensure accuracy.
• Engage withDenials RNsand revenue cycle vendors to implementdenial prevention strategies.
• Ensure compliance with hospital policies regulatory agencies ( Joint Commission) and payer-defined criteria.
• FacilitatePeer-to-Peer reviewsbetween 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