RN Utilization Review-Case Management-FT-1st shift

Overview

The Surgical Utilization Review Registered Nurse (UR RN) is responsible for conducting concurrent medical necessity reviews to ensure appropriate level-of-care determinations, regulatory compliance, and reimbursement integrity. This position serves as a liaison between physicians, advanced practice providers, nursing, case management, revenue cycle, and payer organizations to facilitate accurate patient status assignment, timely authorization management, and denial prevention. The primary focus of this role is surgical utilization review, including pre-operative, post-operative, and procedural patient populations.

Responsibilities

include validating compliance with Medicare, commercial payer, and organizational requirements, including Inpatient Only (IPO) procedures, Two-Midnight Rule criteria, observation services, and medical necessity requirements.This role requires strong collaboration with surgeons, physician assistants, nurse practitioners, hospitalists', and clinical staff to obtain clarifying documentation, facilitate timely order placement, and support appropriate status determinations. The Surgical UR RN is expected to serve as a resource for utilization management best practices and support broader utilization review functions as operational needs dictate.

Qualifications

Required Education: Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) or Licensed Registered Nurse Preferred Education: Bachelors Science Nursing or higher Required

• Experience: 2 years previous nursing experience Preferred
• Experience: Utilization
• Review or Case Management experience Required License/Registration/Certification: Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) or Licensed Registered Nurse Preferred License/Registration/Certification: ACM or CCM Certification Computer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, Microsoft Suite and email applications.