Utlization Review Nurse – Behavioral Health

Utilization Review Nurse (Full-Time)
Up to $10,000 Sign-On Bonus Based on Qualifications and Experience

Donalsonville Hospital is seeking a skilled and detail-oriented Utilization Review (UR) Nurse to join our team. This role is essential to ensuring patients receive high-quality, medically necessary care while supporting the hospital’s compliance, documentation, and insurance processes.

Position Summary
The Utilization Review Nurse is responsible for conducting timely utilization reviews, pre-certifying inpatient and outpatient services with insurance companies, verifying and updating insurance information, and ensuring accurate clinical documentation to support medical necessity. The ideal candidate will have prior UR experience, strong knowledge of payer requirements, and the ability to communicate effectively with physicians, clinical staff, and insurers. Experience in Behavioral Health (BHU) is highly preferred.

Key Responsibilities

• Perform utilization reviews for accuracy, medical necessity, and compliance with payer standards.
• Complete pre-certifications and authorizations for admissions, continued stays, outpatient procedures, and specialty services.
• Verify insurance coverage and update patient insurance information in the electronic medical record.
• Collaborate with physicians and clinical teams to obtain required clinical information for insurance reviews.
• Communicate with insurance representatives to secure initial and continued-stay approvals.
• Review denial letters, assist with peer-to-peer requests, and help support appeals when needed.
• Maintain detailed and accurate documentation of all UR-related activities.
• Monitor BHU patient status, authorizations, and stay requirements when applicable.
• Support throughput and discharge planning by identifying authorization needs early and proactively.

Qualifications

• Active RN license in the State of Georgia (required).
• Previous utilization review or case management experience (required).
• Experience performing pre-certifications and communicating with insurance companies.
• Behavioral Health Unit (BHU) nursing experience is strongly preferred.
• Strong understanding of payer guidelines, clinical documentation standards, and medical necessity criteria (e.g., InterQual, MCG).
• Excellent communication, critical thinking, and organizational skills.
• Proficiency with electronic medical records and insurance authorization portals.

Benefits & Compensation

• Up to $10,000 sign-on bonus based on experience and qualifications.
• Retirement plan, paid time off, and hospital-wide employee benefits.