Utilization Review Nurse

Job Summary : We are seeking a highly motivated and experienced Utilization Review Nurse to join our team. The Utilization Review Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective utilization management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

· Clinical Assessment : Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.

• 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.
• Revenue Cycle Management : Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.

• Utilization Review:

a) Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

b) Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

c) Support Utilization Review Coordinator team members on cases escalated for level of care determinations

d) Screen cases for Physician Advisor review

e) Collaborate with insurance companies on concurrently denied and high risk for denial cases

•   Documentation Improvement : Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

• Data Analysis : Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

• 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.

· Minimum 2 years of work experience in Utilization Review

· 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.