JOB SUMMARY
The Registered Nurse - Utilization Review (Nursing) is responsible for reviewing patient charts and medical records to determine the necessity and appropriateness of medical care and services provided. This role involves collaborating with healthcare providers, insurance companies, and other stakeholders to ensure efficient and effective patient care management.

Key Responsibilities
- Review patient medical records, treatment plans, and diagnostic results to assess medical necessity.
- Determine the appropriateness of care settings and services based on established guidelines and payer policies.
- Communicate with physicians, case managers, and other healthcare professionals to gather information and facilitate care coordination.
- Identify potential issues related to patient care, resource utilization, and discharge planning.
- Interpret and apply payer policies, coverage criteria, and clinical guidelines.
- Document all findings, decisions, and communications accurately in the relevant systems.
- Participate in appeals processes for denied services when necessary.
- Provide education and support to clinical staff regarding utilization review processes and policies.

Schedule / Shift
- Typically Monday through Friday, with potential for flexible scheduling.

Required Qualifications
- Valid Registered Nurse (RN) license in the state of practice.
- Strong understanding of clinical documentation, medical terminology, and healthcare regulations.
- Excellent analytical and critical thinking skills.
- Proficient in utilizing electronic health records (EHR) and other healthcare information systems.
- Ability to work independently and as part of a team.

Preferred Qualifications
- Previous experience in utilization review, case management, or quality improvement.
- Familiarity with various insurance payer policies and procedures.
- Certification in Case Management (CCM) or similar professional credential.

Certifications
- RN License

Experience
- Minimum of 2 years of clinical nursing experience.

Skills
- Medical Record Review
- Clinical Documentation
- Case Management
- Communication and Collaboration
- Problem-Solving
- Attention to Detail
- Time Management
- Payer Policy Interpretation

EMR / Systems
- Experience with electronic health record (EHR) systems is generally required.

Unit / Specialty
- Utilization Review