Registered Nurse; RN; Utilization Management

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Day (United States of America)

As an on-site Hospital Utilization Management (UM) Nurse, you are the primary link between the clinical floor and administrative compliance. Unlike remote roles, this position relies heavily on real‑time, face‑to‑face interaction with doctors, patients, and interdisciplinary teams to optimize hospital resources.

The on-site UM Nurse is a Registered Nurse (RN) responsible for performing admission and concurrent medical record reviews to ensure patients are in the correct Patient Class (e.g., Inpatient vs. Outpatient with Observation). By being physically present, one is able to directly influence the hospital’s throughput, length of stay, and reimbursement accuracy.

• Physician Consultation:
  Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.
• Medical Provider Liaison:
  Function as the primary on-site link between the attending/admitting provider and the Physician Advisor for complex medical necessity determinations.
• Interdisciplinary Huddles:
  Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria‑led care progression.
• ER Throughput Management:
  Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care.
• Medical Necessity Reviews:
  Use criteria like Inter Qual or MCG to perform on-site concurrent reviews of active patient care.
• Issuing Official Notices:
  Deliver and explain legally required documents in person, such as condition-code 44 or Medicare observation notices (MOON).
• Denial Prevention:
  Proactively identify "avoidable days"hospital days that do not meet clinical criteria and upscale them to the management team to minimize financial loss.

Utilization Management Monitors and evaluates patient/clients ongoing plan of care and conducts timely concurrent reviews based on set standards, utilizing screening criteria to monitor care progression with documentation.

Monitors and evaluates the appropriateness of managed care denials and collaborates with attending physician, physician advisors and managed care representative to overturn denials.

Monitors for compliance of Medicare/Medicaid regulations

Meet in person with attending/admitting providers to discuss cases where documentation does not support medical necessity or the current level of care.

Function as the primary on‑site link between the attending/admitting provider and the physician advisor for complex medical necessity determinations.

Attend daily bedside rounds or departmental "bed huddles" to provide immediate input on medical necessity and criteria‑led care progression.

Provide consultation as needed on cases being admitted through the Emergency Department to assess new admissions and recommendations for the most appropriate level of care.

Identifies, participates, and supports continuous performance improvement initiatives based on identified opportunities.

Ensures appropriate compliance with payer regulations and that all information is well documented to prevent payer disputes and…