Utilization Review, RN Flex

Job Summary

A Utilization Review (UR) Nurse is a registered nurse who bridges the gap between healthcare providers and insurance companies. They evaluate patient medical records to ensure treatments, procedures, and hospital stays are clinically necessary, cost-effective, and meet established insurance guidelines.

• Medical Necessity Reviews: They verify that admissions, surgeries, and treatments are medically necessary by comparing patient charts to standardized, evidence-based guidelines like Milliman Care Guidelines (MCG) or InterQual.
• Concurrent & Retrospective Reviews: They review ongoing hospital stays (concurrent) to authorize continuing care, and review charts after discharge (retrospective) to prevent claim denials and ensure accurate billing.
• Insurance Liaison: They act as a go-between, submitting clinical data to insurance companies to secure prior authorizations and ongoing approvals so the hospital gets properly reimbursed.
• Resource Optimization: They monitor the patient's progress to ensure they are in the appropriate level of care (e.g., observation vs. inpatient) and help coordinate discharges to lower levels of care.

Education

* 4 year/ Bachelor's degree in Nursing (Required)

Master's Degree in Nursing (Preferred)

Experience and Skills

Required Skills: Strong Verbal Communications Skills, Strong Written Communications Skills, Excel Intermediate Level, PowerPoint - Intermediate Level, MS Word - Intermediate Level, Excellent Organizational Skills