Utilization Review Nurse
About The Position
The Utilization Review Nurse is responsible for ensuring the medical necessity, appropriateness, and efficiency of inpatient hospital services. This role involves conducting concurrent and retrospective reviews of patient charts, applying standardized clinical criteria to validate admission status, and coordinating with insurance payers to secure timely authorizations. The UR Nurse serves as a vital liaison between the clinical care team and insurance providers to prevent claim denials, facilitate smooth transitions of care, and optimize hospital reimbursement. He/she works collaboratively with physicians and other members of the health care team to ensure that the patient gets the right treatment from resources that are available in the hospital with the most cost effective use of available resources. Is held accountable for policies and procedures of the department and organization.
Requirements
- Registered Nurse with Bachelor's degree or diploma/Associate's degree with Care Management certification within 2 years of hire date (CCM or ACM)
- Bachelor’s Degree in Nursing (BSN)
- Minimum of four (4) years of experience as a RN
- Minimum of three years in acute care hospital
Nice To Haves
- Experience in Case Management, discharge planning or utilization management role
Responsibilities
- Ensuring the medical necessity, appropriateness, and efficiency of inpatient hospital services.
- Conducting concurrent and retrospective reviews of patient charts.
- Applying standardized clinical criteria to validate admission status.
- Coordinating with insurance payers to secure timely authorizations.
- Serving as a vital liaison between the clinical care team and insurance providers to prevent claim denials, facilitate smooth transitions of care, and optimize hospital reimbursement.
- Working collaboratively with physicians and other members of the health care team to ensure that the patient gets the right treatment from resources that are available in the hospital with the most cost effective use of available resources.
- Being held accountable for policies and procedures of the department and organization.
Benefits
- Benefits that complement and support your work/life balance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
