Utilization Review RN
New
J
JobgetherHealthcare utilization review
US; based in the United States, Coverage hours of 8:00 a.m. to 10:00 p.m., including rotating weekendsPart-TimeMiddle
SalaryAnnualized salary range of $63,100–$94,650, depending on experience, education, certifications, and qualifications. Actual compensation will reflect the applicable part-time schedule and employment terms.
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Job Details
- Experience
- Three years of nursing experience in an acute care setting is preferred.
Requirements
- Bachelor's degree in nursing or a related field, or equivalent relevant education and experience.
- Current, unrestricted Registered Nurse (RN) license.
- An active multistate compact RN license is preferred; candidates must already hold one or be willing to obtain one.
- Three years of nursing experience in an acute care setting is preferred.
- Previous utilization review, discharge planning, medical necessity assessment, or related care management experience is an advantage.
- Recent experience or working knowledge of medical necessity review criteria, inpatient and observation status determinations, payer guidelines, and continued-stay reviews is preferred.
- Working knowledge of healthcare quality improvement processes and the ability to identify improvement opportunities.
- Strong clinical judgment, critical thinking, problem-solving, and ability to interpret medical records and determine appropriate resource utilization.
- Strong interpersonal, written, and verbal communication skills for collaboration with physicians, payers, care managers, and other healthcare professionals.
- Strong time management, prioritization, and documentation skills, including managing multiple reviews and competing deadlines.
- Comfort using digital communication platforms, electronic documentation systems, and clinical review tools; reliable high-speed internet access is required.
- Ability to work within coverage hours of 8:00 a.m. to 10:00 p.m., including rotating weekends, and willingness and ability to travel to client, temporary, or corporate locations when required.
Responsibilities
- Conduct clinical reviews of inpatient admissions, observation stays, and continued hospital stays using approved medical necessity criteria.
- Evaluate diagnoses, costs, complications, and clinical indicators to identify potential overutilization or underutilization, and refer cases to physician advisors when needed.
- Collaborate with physicians, care managers, and interdisciplinary teams to clarify clinical information, obtain supporting documentation, and address barriers to patient progress.
- Submit clinical reviews to commercial insurance carriers within required timeframes and communicate review outcomes to relevant stakeholders.
- Document reviews, coordinate peer-to-peer discussions and appeals when assigned, track overturned days, and monitor denial trends.
- Work with financial clearance, patient access, financial counseling, and business office teams to resolve third-party payer billing concerns.
- Support quality and performance initiatives, including applicable CMS indicators, and participate in departmental improvement projects.
- Maintain statistical records, complete system work queues, document communications and outcomes, and submit required information by deadlines.
- Communicate coverage and non-coverage determinations to physicians and patients as appropriate, and educate hospital and medical staff about utilization review requirements.
- Follow departmental policies, protect patient confidentiality and rights, and maintain current knowledge of medical necessity criteria, payer requirements, MS-DRGs, present-on-admission indicators, and relevant regulations.
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