Registered Nurse - Utilization Review

The R egistered Nurse – Utilization Review is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. This role ensures compliance with payer requirements, regulatory standards, and organizational policies while collaborating with physicians, case managers, and insurance providers to support quality patient care and cost-effective resource utilization. Key Responsibilities C onduct utilization reviews to assess medical necessity and appropriateness of patient care Review clinical documentation and patient records for compliance with payer and regulatory requirements Collaborate with physicians, case managers, and insurance providers to coordinate care and approvals Ensure adherence to guidelines including CMS, Joint Commission, and organizational standards Communicate review outcomes to physicians, insurance providers, and patients as appropriate Support appeals processes by providing documentation and clinical justification for denied claims Participate in quality improvement initiatives related to utilization management and patient outcomes Required Qualifications Active Registered Nurse license in the state of practice Minimum of 2–3 years clinical nursing experience (medical/surgical, critical care, or case management preferred) Strong knowledge of clinical standards and payer requirements Excellent analytical and communication skills for interpreting medical records and interacting with stakeholders Proficiency in electronic medical records (EMR systems and utilization management tools) Preferred Qualifications E xperience in utilization management or case management Familiarity with insurance authorization processes and appeals procedures Certification in Utilization Review or Case Management (e.g., CCM, CPUR, CPHQ) Certifications Active RN license required Additional certifications in utilization review or case management preferred #J-18808-Ljbffr