Utilization Review Registered Nurse - 40 hours

MaineGeneral Health•Augusta, ME

7d•Onsite

About The Position

MaineGeneral Health is seeking an experienced Utilization Review Registered Nurse (RN) to join our collaborative Utilization Review team. This role is ideal for an RN who enjoys using their clinical expertise to support appropriate patient care, navigate medical necessity and reimbursement, and work collaboratively with a multidisciplinary team. The Utilization Review team is a supportive group that works closely together, sharing knowledge and collaborating on clinical and utilization decisions. This position provides an opportunity to use your nursing experience in a role focused on patient care coordination, utilization management, documentation, and reimbursement.

Requirements

Current Maine Registered Nurse (RN) license or the ability to obtain Maine licensure in a timely manner.
Strong clinical assessment, critical thinking, and decision-making skills.
Excellent communication and collaboration skills.
Ability to work independently while contributing effectively as part of a team.

Nice To Haves

Utilization Review or Care Management experience strongly preferred.
Knowledge of medical necessity, reimbursement guidelines, and clinical documentation preferred.

Responsibilities

Reviews admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
Assists multidisciplinary teams with issues related to medical records/documentation, pre-certifications, reimbursement and claim denials/appeals.
Collaborates to assess and coordinate patient's discharge planning needs with members of the healthcare team.
Monitors for delays in care and prepares data to reduce length of stay and maximize reimbursement.