RN, Utilization Review
About The Position
The RN, Utilization Review performs advanced utilization review functions to ensure compliance with payer requirements and optimize clinical documentation for accurate reimbursement. The role conducts detailed medical necessity reviews for inpatient and outpatient services, prepares and submits authorization requests, and manages complex cases requiring escalation. It collaborates with providers, payers, and internal teams to resolve authorization issues, reduce denials, and support revenue integrity. The position also mentors other associates, analyzes denial trends, contributes to process improvement initiatives, and applies strong clinical judgment and regulatory knowledge.
Requirements
- Registered Nurse (RN); the job title identifies the role as an RN.
- Strong clinical judgment and regulatory knowledge.
Responsibilities
- Conduct detailed medical necessity reviews for inpatient and outpatient services.
- Prepare and submit authorization requests.
- Manage complex cases requiring escalation.
- Collaborate with providers, payers, and internal teams to resolve authorization issues, reduce denials, and support revenue integrity.
- Mentor other associates.
- Analyze denial trends.
- Contribute to process improvement initiatives.
- Apply clinical judgment and regulatory knowledge to utilization review functions.
Benefits
- Comprehensive benefits package supporting physical, emotional, and financial health, including healthcare, time off, retirement, and well-being programs.
- Professional development investment and a professional certification relevant to each associate’s field.
- Tuition reimbursement.
- Quarterly and annual incentive programs for employees who exceed expectations.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
