Utilization Review Nurse

UTILIZATION REVIEW NURSE

This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

1. Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.
2. Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
3. Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.
4. Utilization Review:

• Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays
• Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients
• Support Utilization Review Coordinator team members on cases escalated for level of care determinations
• Screen cases for Physician Advisor review
• Collaborate with insurance companies on concurrently denied and high risk for denial cases

1. Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.
2. Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.
3. Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications:

• Registered Nurse (RN) licensure required; must hold a USRN multi-state/compact nursing license.
• Bachelor of Science in Nursing (BSN) preferred.
• Case Management Certification (e.g., CCM) is a plus.
• Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.
• Strong understanding of revenue cycle management and healthcare reimbursement.
• Proficiency in medical coding and clinical documentation improvement.
• Excellent communication, interpersonal, and teamwork skills.
• Ability to work independently and make sound clinical and financial decisions.
• Strong analytical and problem-solving skills.
• Proficient in using healthcare information systems and technology.
• Commitment to maintaining patient confidentiality and ethical standards.

Benefits:

• Competitive salary
• Comprehensive healthcare benefits
• Professional development and training opportunities
• Collaborative and supportive work environment
• Opportunities for advancement within the company
• Work-life balance programs