Job Details
Position Summary:
We are seeking an experienced Utilization Review Registered Nurse (RN) to evaluate the medical necessity, appropriateness, and efficiency of healthcare services. The Utilization Review RN will collaborate with physicians, case managers, insurance providers, and the healthcare team to ensure compliance with regulatory guidelines while promoting quality patient care and effective resource utilization.
Key Responsibilities:
- Review patient medical records to determine medical necessity and appropriateness of admissions, continued stays, and services.
- Perform concurrent and retrospective utilization reviews in accordance with established guidelines.
- Coordinate prior authorizations and communicate with insurance providers regarding coverage determinations.
- Collaborate with physicians, case managers, and interdisciplinary teams to optimize patient care and discharge planning.
- Monitor length of stay and identify opportunities to improve resource utilization.
- Ensure compliance with CMS, Medicare, Medicaid, commercial payer, and facility utilization review guidelines.
- Maintain accurate documentation in the Electronic Medical Record (EMR) and utilization management systems.
- Participate in appeals, denials management, and peer-to-peer review processes as needed.
- Educate clinical staff on utilization review processes and regulatory requirements.
- Participate in quality improvement initiatives and continuing education activities.
Required Qualifications:
- Active, unrestricted Registered Nurse (RN) license in the state of practice.
- Graduate of an accredited Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) program.
- Current BLS certification required.
- Minimum 2 years of recent clinical nursing experience.
- Minimum 1 year of Utilization Review, Case Management, Care Coordination, or Utilization Management experience preferred.
- Strong knowledge of medical necessity criteria (InterQual, MCG, or similar), reimbursement guidelines, and regulatory requirements.
- Excellent analytical, communication, organizational, and critical-thinking skills.
- Proficiency with Electronic Medical Record (EMR) systems and Microsoft Office applications.
Preferred Qualifications:
- Bachelor of Science in Nursing (BSN) preferred.
- Experience in acute care hospital utilization review or case management.
- Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification preferred.
- Familiarity with Medicare, Medicaid, commercial insurance, and payer authorization processes.
- Strong ability to manage multiple priorities while maintaining accuracy and compliance.
Pay Rate
$64.28 - $69.16/hour
About us :
At MedCadre , we’re dedicated collaborators, bridging the gap between top-tier professionals and healthcare organizations that prioritize excellence. By fostering transparent communication and leveraging deep industry expertise, we build enduring partnerships rooted in trust.
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