Job Description

Job Summary

We are seeking an experienced Registered Nurse (RN) - Utilization Review to evaluate the medical necessity, appropriateness, and level of care for patients. The RN will review clinical documentation, apply established medical guidelines, and collaborate with physicians, case managers, health plans, and other healthcare professionals to ensure appropriate utilization of healthcare services.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews of patient records.
• Evaluate medical necessity and appropriateness of admissions, continued stays, procedures, and levels of care.
• Review clinical documentation and medical records to determine whether services meet established criteria.
• Apply evidence-based guidelines such as InterQual, MCG, CMS, and payer-specific criteria, as applicable.
• Communicate with physicians and other healthcare providers regarding clinical information and utilization decisions.
• Identify opportunities for appropriate resource utilization and cost-effective care.
• Collaborate with Case Management, Quality Management, Medical Directors, and insurance companies.
• Prepare and maintain accurate documentation of utilization review activities.
• Escalate cases to the appropriate physician advisor or Medical Director when criteria are not met or additional clinical review is required.
• Assist with authorization requests, denials, appeals, and reconsiderations when applicable.
• Ensure compliance with applicable healthcare regulations, organizational policies, and payer requirements.
• Maintain confidentiality of patient information in accordance with HIPAA regulations.

Required Certifications & Licensure

• New York State RN License.
• Primary Source Verification.
• AHA BLS.

Required Skills & Experience

• One (1) year of non-acute utilization review experience.

Preferred Skills & Experience

• RN experience.

Skills

• Non-acute utilization review.

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