Utilization Management Registered Nurse

Utilization Management Department (Fully Remote)

Provides health care services regarding admissions, case management, discharge planning and utilization review.

Reviews admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases.

Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals.

Assesses and coordinates discharge planning needs with healthcare team members.

May prepare statistical analysis and utilization review reports as necessary.

Oversees and coordinates compliance to federally mandated and third party payer utilization management rules and regulations.

Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment.