Utilization Review Registered Nurse

Job Overview The Utilization Review RN is responsible for utilization management and review for prospective, concurrent, or retrospective cases. The role functions within a multidisciplinary team including physicians, social workers, discharge planning assistants, and payers, evaluating medical appropriateness of inpatient and outpatient services per guidelines and benefit determination. Responsibilities Conduct prospective, concurrent, and retrospective utilization reviews for inpatient services, observation services, and specific outpatient service requests. Determine medical appropriateness of inpatient and outpatient services by evaluating medical guidelines and benefit determinations. Collaborate with attending and consulting physicians to facilitate efficient transitions during hospitalization. Work with the multidisciplinary team to coordinate care and ensure reimbursement aligns with payer contracts and efficient resource use. Use medical necessity criteria to assess level and setting of care, assist in denial and appeals, evaluate quality, and identify potential risk management issues. Participate in all patient safety initiatives relevant to the position. Maintain professional rapport with providers, patients/families, and internal customers. Train and educate new UM staff nurses and new RN Care Coordinators on job competency and technical instruction. Advocate for appropriate placement of patients to secure correct remuneration. Utilize clinical application systems, utilization review systems, and business support applications. Qualifications Licensed Registered Nurse in the State of Virginia (or eligible). Current RN licensure in Virginia. Minimum of three (3) years of nursing experience in an acute care setting. Completion of 15 continuing education units per year. Proficiency in Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management. Preferred Experience and Credentials One (1) year of Care Coordination experience. Clinical experience with specialty patient populations. Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or managed care organization (HMO/TPA/IPA/etc.). Master’s Degree in Nursing or a healthcare-related field from an accredited program. Case Management Certification. Additional Position Requirements Ability to flex the schedule as needed to meet department demands. Physical lifting capacity of 20-50 lbs.; prolonged sitting; repetitive motion. Strong recall, reasoning, problem solving, hearing, speaking, writing, reading, logical thinking. Ability to handle multiple priorities, frequent customer interactions, and adapt to frequent change. EEO Statement EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4. #J-18808-Ljbffr VCU Health