Registered Nurse Utilization Review

Ascension•Pensacola, FL

2d•$84,061 - $118,669•Remote

About The Position

Perform prospective, concurrent, and retrospective reviews of admissions and service requests using evidence-based criteria (e.g., InterQual, MCG) to ensure medical necessity and adherence to reimbursement policies. Manage and consult on high-acuity or complex cases, coordinating with the multidisciplinary team to ensure the level of care matches the patient’s clinical status and facility protocols. Mitigate financial risk by overseeing compliance with federal (CMS) and third-party payer regulations, assisting staff with precertification, accurate coding, and the management of claim denials or appeals. Lead the healthcare team in assessing and coordinating discharge needs, ensuring safe patient transitions while preparing statistical reports to identify trends in resource utilization.

Requirements

Licensed Registered Nurse credentialed from the Florida Board of Nursing obtained prior to hire date or job transfer date required.
Licensed as a Registered Nurse in Florida required.
Credentialed from State Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date required.
Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire.
3+ years of clinical experience required.
Observation experience.
Experience in Utilization Management, Case Management, or Care Coordination.
Experience working in a remote environment.

Responsibilities

Perform prospective, concurrent, and retrospective reviews of admissions and service requests using evidence-based criteria (e.g., InterQual, MCG) to ensure medical necessity and adherence to reimbursement policies.
Manage and consult on high-acuity or complex cases, coordinating with the multidisciplinary team to ensure the level of care matches the patient’s clinical status and facility protocols.
Mitigate financial risk by overseeing compliance with federal (CMS) and third-party payer regulations, assisting staff with precertification, accurate coding, and the management of claim denials or appeals.
Lead the healthcare team in assessing and coordinating discharge needs, ensuring safe patient transitions while preparing statistical reports to identify trends in resource utilization.