RN Utilization Review

Job Summary

We are seeking an experienced Registered Nurse (RN) - Utilization Review to evaluate the medical necessity appropriateness and level of care for patients. The RN will review clinical documentation apply established medical guidelines and collaborate with physicians case managers health plans and other healthcare professionals to ensure appropriate utilization of healthcare services.

Key Responsibilities

• Conduct prospective concurrent and retrospective utilization reviews of patient records.
• Evaluate medical necessity and appropriateness of admissions continued stays procedures and levels of care.
• Review clinical documentation and medical records to determine whether services meet established criteria.
• Apply evidence-based guidelines such as InterQual MCG CMS and payer-specific criteria as applicable.
• Communicate with physicians and other healthcare providers regarding clinical information and utilization decisions.
• Identify opportunities for appropriate resource utilization and cost-effective care.
• Collaborate with Case Management Quality Management Medical Directors and insurance companies.
• Prepare and maintain accurate documentation of utilization review activities.
• Escalate cases to the appropriate physician advisor or Medical Director when criteria are not met or additional clinical review is required.
• Assist with authorization requests denials appeals and reconsiderations when applicable.
• Ensure compliance with applicable healthcare regulations organizational policies and payer requirements.
• Maintain confidentiality of patient information in accordance with HIPAA regulations.

• New York State RN License.
• Primary Source Verification.
• AHA BLS.

• One (1) year of non-acute utilization review experience.

• RN experience.

• Non-acute utilization review.

Required Skills:

RNREGISTERED NURSE