Registered Nurse (RN) - Utilization Review

Up to $20,000 Sign-on Bonus Based on Eligibility

The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case by case basis.

• Coordinates clinical care and resource utilization by evaluating medical necessity, appropriateness of care, continued stay, and discharge planning in accordance with evidence-based practices and regulatory requirements.
• Completes and submits admission and concurrent reviews to payers, securing authorizations and identifying/documenting avoidable days to improve clinical and financial outcomes.
• Ensures timely communication and documentation of clinical information to payers to support admissions, level of care, length of stay, and authorization requirements.
• Advocates for patients and the organization with payers to obtain appropriate reimbursement, prevent denials, and manage dispute resolution processes, including secondary reviews and peer-to-peer appeals.
• Provides education and guidance to physicians and the healthcare team regarding care progression, appropriate level of care, safe patient transitions, and available patient resources and benefits.
• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services.
• Required:
• Education: Associates in Nursing required
• Experience: At least two years acute hospital or Behavioral Health patient care experience.
• Licensure/Certification: Required qualifications include an active Registered Nurse license
• Preferred:
• Education: BSN
• Licensure/Certification: Accredited Case Manager (ACM) preferred