Utilization Review RN

To support effective utilization management, the full-time remote Utilization Review RN will examine medical records, develop clinical reviews for authorization, and collaborate with interdisciplinary teams to optimize reimbursement and prevent payment denials. Key responsibilities: Review and evaluate clinical information to support Utilization Management decisions based on medical documentation Facilitate communication with payors regarding medical necessity and coordinate the authorization process Advocate for patients and the hospital to optimize reimbursement and manage concurrent denials Required qualifications: Current Registered Nurse license in the applicable state or multi-state license through the enhanced Nurse Licensure Compact (eNLC) Three years of healthcare clinical experience Knowledge of medical terminology and third-party payers Experience in Utilization Management or Medical Management for Medicare and/or Medicaid populations is preferred Bachelor's Degree in Nursing or currently enrolled in a BSN program with completion within three years of hire is preferred