RN Utilization Review-Case Management-FT-1st shift

HH Health System • Huntsville, AL

4d • Onsite

About The Position

The Surgical Utilization Review Registered Nurse (UR RN) is responsible for conducting concurrent medical necessity reviews to ensure appropriate level-of-care determinations, regulatory compliance, and reimbursement integrity. This position serves as a liaison between physicians, advanced practice providers, nursing, case management, revenue cycle, and payer organizations to facilitate accurate patient status assignment, timely authorization management, and denial prevention. The primary focus of this role is surgical utilization review, including pre-operative, post-operative, and procedural patient populations. Responsibilities include validating compliance with Medicare, commercial payer, and organizational requirements, including Inpatient Only (IPO) procedures, Two-Midnight Rule criteria, observation services, and medical necessity requirements. This role requires strong collaboration with surgeons, physician assistants, nurse practitioners, hospitalists', and clinical staff to obtain clarifying documentation, facilitate timely order placement, and support appropriate status determinations. The Surgical UR RN is expected to serve as a resource for utilization management best practices and support broader utilization review functions as operational needs dictate.

Requirements

• Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) or Licensed Registered Nurse
• 2 years previous nursing experience
• Data entry skills
• Demonstrable skills with Google Docs, Google Sheets, Microsoft Suite and email applications.

Nice To Haves

• Bachelors Science Nursing or higher
• Utilization Review or Case Management experience
• ACM or CCM Certification

Responsibilities

• Conducting concurrent medical necessity reviews to ensure appropriate level-of-care determinations, regulatory compliance, and reimbursement integrity.
• Serving as a liaison between physicians, advanced practice providers, nursing, case management, revenue cycle, and payer organizations to facilitate accurate patient status assignment, timely authorization management, and denial prevention.
• Validating compliance with Medicare, commercial payer, and organizational requirements, including Inpatient Only (IPO) procedures, Two-Midnight Rule criteria, observation services, and medical necessity requirements.
• Collaborating with surgeons, physician assistants, nurse practitioners, hospitalists', and clinical staff to obtain clarifying documentation, facilitate timely order placement, and support appropriate status determinations.
• Serving as a resource for utilization management best practices and supporting broader utilization review functions as operational needs dictate.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed