Utilization Review RN- Case Management
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About The Position
The Utilization Review (UR) Nurse is a registered nurse who provides clinical review against nationally recognized medical necessity criteria for the purpose of evaluating medical necessity or hospitalization (inpatient and outpatient observation patients) regardless of payer type. The UR RN provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent and retrospective reviews. The UR RN provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. The UR RN communicates with the Lead UR RN when potential medical necessity denials are determined by the payer. Both the UR RN and the Lead UR RN partner with physicians related to medical necessity appropriateness of admission and prevention of denials.
