Utilization Review, RN Flex

Job Requirements 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. Work Experience 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