Registered Nurse; RN; Utilization Review - PRN

Role: Utilization Management Nurse (UM) Coordinator, responsible for conducting 24/7 medical necessity reviews, obtaining authorizations, and facilitating safe transitions of care.

• Perform clinical reviews using established criteria (e.g., MCG, mcg Indicia) for admissions, observation, and ongoing care.
• Coordinate with payers, physicians, and care teams to secure timely authorizations and resolve discrepancies pre-billing.
• Document all review activities accurately in electronic systems like EPIC and communicate effectively with stakeholders.
• Monitor patient care plans, evaluate appropriateness of care, and advocate for patients outside coverage if needed.
• Support compliance with regulations, participate in performance improvement initiatives, and serve as a mentor or preceptor.

• Minimum of 3 years clinical practice experience.
• RN license (single-state or multi-state compact) and BLS certification required.
• Strong knowledge of case management, clinical criteria, and documentation standards.
• Excellent verbal and written communication, organizational, and critical thinking skills.
• Proficient in clinical data review, utilizing screening criteria, and computer systems.

Additional Info: This PRN role involves working various shifts, including holidays, with responsibilities centered on clinical review, documentation, and collaboration to ensure appropriate care and billing processes.