RN Utilization Review

ID: Shift: Day 5x8-Hour (08:30 - 17:00) Description: Utilization Review Nurse*THIS IS NOT A REMOTE POSITION. It is an in person :5x8 s; M-F; 8:30 5pmNo WeekendsNo CallEDUCATIONGraduate from an accredited school of nursing BSN of two (2) years of Utilization Review experience. EPIC experience is requiredAcute Hospital experience is requiredMust have travel experience. SKILLS:Utilization Review experience required. Experience in Denials Management Insurance Denials Peer-to-peer Appeals is preferred. Experience with completing Utilization Review in the hospital setting and using InterQual and MCG evaluation criteria to justify admissions and level of care with insurance companiesLICENSURE /CERTIFICATIONNC or compact state RN licenseBLS RequiredACM/CCM Preferred Average daily census : 30Orientation: 24 hoursThis position facilitates utilization management processes to support the right care is provided at the right place at the right time. To accomplish these goals the UR Nurse applies established criteria to evaluate the appropriateness of admission level of care continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care service or transition of care delays/issues as necessary; in collaboration with the care team. This position provides third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team patient family and others. Communicates with physicians for appropriate documentation to support authorization of services. Modified Time:5/11/2026 4:00:00 AM Account Manager: Haley Hindes Account Manager Email: COVID-19 Vaccine: Unknown Flu Vaccine: Unknown Submittals:Med Job Requirements & Qualifications Previous Charge Experience : - Years of Experience : 2 Patient Ratio Experience : Charting System Experience : Required Charting System Name : Epic Community Hospital Experience : Preferred LTAC Experience : - Trauma Level I Experience : - Trauma Level II Experience : - Travel Experience Required : Yes Certifications : BLS RN state license ACM/CCM*Skills : Acute Hospital Admission Criteria Admission Criteria Appeals and Denials* Appeals and Denials* Concurrent Review Concurrent Review Continued Stay Reviews Continued Stay Reviews Determine Medical Necessity per Evidence-Based Guidelines Medical Necessity Pre-Cert Review* Prior Authorization Prior Authorizations Retrospective Review* Retrospective Review* Utilize InterQual Criteria Utilize InterQual Criteria Utilize Milliman Guidelines Utilize Milliman Guidelines Payor Portals* Unit Details Staffing & Scheduling Scheduling Type : - Patient Ratios Days : - Patient Ratios Nights : - Patient Ratios Weekends : - Float Required : - Call Required : - Weekend Coverage : - Number of Weekend Shifts Per Contract : - Pre-Approved Time Off : - Orientation Hours : 24 Facility & Patient Care Details Patient Age Groups : Adults Geriatrics Daily Census : 30 Number of Visits Per Day : - Number of Rooms : - Number of Beds : - Additional Unit Information Interdisciplinary Support : - Patient Diagnoses : Utilization Review experience required. Experience in MCG and Interqual in Denials Management Insurance Denials Peer-to-peer Appeals is preferred. Experience in payor portals/reviewing portals for authorization/denial determination preferred. Special Procedures/Unit Details : This position facilitates utilization management processes to support the right care is provided at the right place at the right time. To accomplish these goals the UR Nurse applies established criteria to evaluate the appropriateness of admission level of care continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care service or transition of care delays/issues as necessary; in collaboration with the care team. This position provides third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team patient family and others. Communicates with physicians for appropriate documentation to support authorization of services. Special Equipment : - #Tier1 Travel Compliance Submittal Details: #Tier1 Travel Compliance Guaranteed Hours: Contract Weeks:91