Utilization Review RN

About This Opportunity

We are representing a confidential healthcare organization seeking a Utilization Review RN to join their revenue cycle team. This remote position requires a skilled registered nurse who specializes in examining medical records, developing clinical reviews to support authorization processes, and optimizing reimbursement outcomes.

The ideal candidate will have acute knowledge in utilization management, medical necessity determination, and patient status assessment. You'll be responsible for performing initial and concurrent utilization reviews, communicating effectively with payors, and collaborating with interdisciplinary teams to prevent concurrent denials.

Responsibilities

• Review, assess, and evaluate clinical information to support utilization management decisions based on medical record documentation
• Compile concise and pertinent clinical reviews to support authorization obtainment and avoid payment denials
• Ensure effective communication of medical necessity to applicable payors with adherence to quality and timeline standards
• Collaborate with coordinators, clinical appeals teams, and physician advisors to prevent and manage concurrent denials
• Advocate for the patient and facility with insurance companies to optimize reimbursement and coverage
• Provide timely and comprehensive documentation of clinical reviews and payor communication
• Maintain working knowledge of payor requirements, federal regulations, and Conditions of Participation
• Communicate concurrent denials to appropriate team members in a timely fashion
• Provide effective reconsideration clinicals to payors to prevent denials
• Determine appropriate admission status based on regulatory and reimbursement requirements
• Participate in process improvement initiatives across departments
• Coordinate communication with physicians to ensure appropriate patient status determination
• Provide orientation, training, and competency development for staff and colleagues

What We're Looking For

Required Qualifications:

• Current Registered Nurse license or multi-state RN license through the enhanced Nurse Licensure Compact (eNLC)
• Three (3) years of healthcare clinical experience
• Effective verbal and written communication skills
• Strong interpersonal skills and attention to detail
• Knowledge of medical terminology
• Knowledge of third-party payers
• Working knowledge of computers and business equipment
• Excellent customer service and telephone etiquette
• Ability to use tact and diplomacy when dealing with others

Preferred Qualifications:

• Bachelor's Degree in Nursing, or ASN/Diploma with current enrollment in BSN program
• Medical Management experience for Medicare and/or Medicaid populations
• Prior Utilization Management experience

Work Environment:

• Remote office work with extended periods of sitting
• Confidential home office space required
• Weekends and holidays as assigned
• 40 hours per week scheduled

How We Work With You

Our talent team at Get A Job.ai partners with healthcare organizations to connect qualified nursing professionals with career opportunities. When you apply through our platform, a dedicated recruiter will review your qualifications and conduct an initial screening. If there's a strong match, we'll submit your profile to our client for consideration. Please do not attempt to contact the employer directly, as all communications are managed through Get A Job.ai to ensure a professional and organized hiring process.

Pay

Compensation details will be discussed during the screening process with our recruiting team.

Equal Employment Opportunity: Get A Job.ai is committed to providing equal employment opportunities to all applicants and works with client organizations that share our values of diversity and inclusion.