Utilization Review Nurse RN - PRN

Position Summary

The Utilization Review Nurse is responsible for conducting initial, concurrent, and retrospective medical record reviews to evaluate the appropriateness of patient care, resource utilization, and reimbursement. This role collaborates closely with Care Management, physicians, patient access, financial counselors, and third-party payers to ensure accurate clinical documentation, timely authorization, and effective coordination of care while minimizing avoidable delays and payment denials.

Key Responsibilities

• Perform initial, concurrent, and retrospective utilization reviews using established clinical criteria to evaluate medical necessity, level of care, and resource utilization.
• Review medical records for clinical, financial, and utilization management information and accurately document findings in the designated utilization management software.
• Communicate with third-party payers to obtain certifications, authorizations, and continued stay approvals by providing relevant clinical information.
• Monitor utilization trends, identify potential or actual denials, and implement interventions to reduce avoidable delays and reimbursement issues.
• Collaborate with Care Managers, Social Workers, physicians, financial counselors, and patient access staff to coordinate patient care and support appropriate discharge planning.
• Assist Care Managers in communicating denied hospital days and issuing required Medicare notices, including the Hospital-Issued Notice of Noncoverage (HINN) and Detailed Notice of Discharge, to patients and families when appropriate.
• Coordinate with Care Management to promote efficient patient throughput, optimize length of stay, and improve patient outcomes.
• Escalate cases that do not meet medical necessity criteria to the Physician Advisor for review and recommendations.
• Partner with the Physician Advisor and interdisciplinary team to facilitate expedited appeals and resolve payer-related issues.
• Maintain compliance with organizational policies, payer requirements, regulatory standards, and documentation guidelines.
• Identify opportunities for process improvement within utilization management and contribute to quality initiatives.
• Perform other duties as assigned.

Qualifications

Required

• Active Registered Nurse (RN) license in good standing.
• Knowledge of utilization review, medical necessity criteria, reimbursement processes, and payer regulations.
• Strong clinical assessment and critical thinking skills.
• Excellent communication, documentation, and organizational skills.
• Ability to work collaboratively with interdisciplinary teams and external payer representatives.
• Proficiency with electronic health records (EHR) and utilization management software.
• Previous experience in Utilization Management, Case Management, or Care Coordination.
• Experience using InterQual®, MCG®, or other evidence-based utilization review criteria.
• Certification in Case Management (CCM), Utilization Review (CPUR), or a related specialty preferred.

Benefits

• Competitive PRN rate
• Flexible Schedule
• Paid time off and holidays
• Collaborative and supportive work environment