Utility Management Nurses

Role Overview

Were seeking experienced Utility Management Nurses to support a clients healthcare product development by leveraging expertise in insurance coding and hospital revenue management workflows. This role involves collaborating with hospital systems to align medical documentation with insurance policies ensuring accurate coding and optimal reimbursement outcomes.

Key Responsibilities

• Insurance Coding & Revenue Cycle Alignment: Review audit and optimize insurance coding practices across hospital systems to ensure compliance and maximize reimbursement accuracy.

• Workflow Analysis: Evaluate existing revenue management workflows and recommend improvements tailored to clients AI-driven documentation tools.

• Clinical Data Interpretation: Translate complex clinical notes into standardized coding formats (ICD-10 CPT HCPCS) aligned with payer policies.

• Policy Matching: Assess coding accuracy against insurance guidelines and payer documentation requirements.

• Product Development Collaboration: Work closely with clients engineering and product teams to refine AI models that automate or assist with medical coding and documentation.

• Compliance & Quality Assurance: Ensure alignment with HIPAA CMS and payer-specific coding regulations.

Required Qualifications

• Licensure: Registered Nurse (RN) or equivalent clinical background.

• Experience: Minimum 35 years in medical coding clinical documentation improvement (CDI) or revenue cycle management.

• Certifications: CPC CCS or CRC certification preferred.

• Domain Expertise: Familiarity with hospital billing systems payer policy interpretation and coding audit procedures.

• Analytical Skills: Strong understanding of clinical documentation standards and payer logic.

• Tech Savvy: Comfortable working with EHR systems (Epic Cerner Meditech) and documentation review software.

Preferred Qualifications

• Experience working within hospital revenue integrity teams or insurance utilization management.

• Exposure to AI-powered healthcare documentation tools or automated coding systems.

• Ability to identify and flag edge cases or policy exceptions in automated workflows.

• Strong collaboration skills with cross-functional (engineering compliance and data) teams.

Engagement Model

• Contract / Part-time (Remote/In person) Flexible hours with collaboration during U.S. business person in San Francisco is a plus