Utilization Review Registered Nurse

The Utilization Review Registered Nurse is responsible for ensuring appropriate patient status, medical necessity, and payer compliance through prospective, concurrent, and retrospective review. 

This role serves as the clinical lead for utilization management and a key contributor to denial prevention, partnering closely with Denial Management and Revenue Cycle teams to proactively identify, mitigate, and reduce denial risk. The role also collaborates closely with Case Management to align patient status, authorization, and progression of care with payer requirements.

Essential Duties and Responsibilities:

1. Conduct admission and concurrent medical necessity reviews using InterQual or Milliman criteria.
2. Ensure appropriate patient status designation, including inpatient versus observation level of care.
3. Obtain, validate, and maintain payer authorizations and required notifications.
4. Identify, escalate, and help mitigate cases at risk for denial.
5. Collaborate with physicians to support accurate and complete clinical documentation.
6. Serve as a liaison with payers during concurrent reviews, authorization inquiries, and peer-to-peer discussions.
7. Partner with Denial Management and Revenue Cycle teams to identify denial trends and implement prevention strategies.
8. Maintain accurate and timely documentation of utilization review activities.
9. Ensure compliance with CMS, regulatory, and payer requirements.
10. Perform daily census reviews to validate patient status, medical necessity, and authorization requirements.
11. Prioritize high-risk cases, including extended observation stays, high-cost encounters, and incomplete or pending authorizations.
12. Lead real-time denial prevention efforts through early identification of documentation, authorization, and medical necessity gaps.
13. Prepare clinical information and support peer-to-peer reviews by aligning documentation with payer criteria.
14. Provide timely feedback to physicians regarding documentation opportunities that may impact medical necessity determinations and reimbursement.
15. Monitor patient progression against expected length of stay and evidence-based clinical criteria.
16. Identify and escalate barriers that may impact payer approval, patient status, authorization, or reimbursement.
17. Collaborate with Case Management to ensure alignment between payer requirements and discharge readiness without assuming discharge planning responsibilities.
18. Participate in denial trend analysis, quality initiatives, and process improvement efforts.
19. Support audit activities, including RAC, governmental, and commercial payer audits, and participate in pre-bill review processes as needed.

• Education & Training:
  • Associate's degree in nursing required.
  • Bachelor's degree in nursing preferred.
• Experience:
  • 3 years of acute care experience required.
  • Experience in utilization review or case management preferred.
• Licensure/Certification/Registration:
  • Current RN license in the state of Texas required
  • BLS required
  • Must possess and maintain a valid driver’s license as employees may occasionally be required to operate a company vehicle. Reasonable accommodations may be provided as required by law.
• Key Skills:
  • Comprehensive knowledge of CMS regulations, utilization management standards, and commercial payer requirements.
  • Strong communication, collaboration, critical thinking, and analytical skills.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable law.