Utilization Management RN - Revenue Integrity

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Reporting to the Associate Director of Specialty and Payer Management, the Clinical Reviewer is a non-patient-facing nursing professional who supports medical necessity reviews, authorization compliance, reimbursement optimization, and denial prevention. The role evaluates medical records, treatment plans, and payer policies to ensure services meet coverage criteria and regulatory standards.

The Clinical Reviewer serves as a liaison between providers, payers, and operational teams, translating clinical information into payer-specific documentation and authorization strategies. This administrative and analytical role requires strong clinical judgment, critical thinking, and knowledge of healthcare reimbursement and utilization management to reduce denials and support timely access to medically necessary care.

• Clinical Review and Medical Necessity:
  Review documentation against payer policies and medical necessity criteria, identify gaps, and guide improvements to support authorization and reimbursement.
• Authorization and Payer Policies:
  Interpret payer requirements and advise providers and operational teams on compliance and discrepancies between authorized and performed services.
• Denials and Appeals:
  Prepare clinical summaries and medical necessity rationales for first-level, second-level, and external appeals; support provider preparation for peer-to-peer discussions; and identify ways to prevent recurring denials.
• Revenue Integrity:
  Identify and help resolve reimbursement risks related to authorization discrepancies and clinical documentation deficiencies.
• Provider Education and
  
  Collaboration:
  
  Serve as a clinical resource for providers and revenue cycle teams, communicating payer requirements and proactively addressing reimbursement barriers.

1. Licensure as a Registered Nurse in the State of Connecticut or eligible for Connecticut licensure.

2. Experience in utilization management, case management, prior authorization, revenue cycle, specialty pharmacy, managed care, or related healthcare operations preferred.

3. Knowledge of medical necessity criteria, payer guidelines, and healthcare reimbursement processes.

4. Strong critical thinking and clinical assessment skills.

5. Proficiency with electronic health records and payer portal systems.

6. Excellent written and verbal communication skills.

1. Certification such as:

• Certified Case Manager (CCM)

• Certified Professional Utilization Review (CPUR)

• Accredited Case Manager (ACM)

2. Experience with Medicare, Medicaid, and commercial payer policies.

3. Experience with specialty medications, infusion therapies, oncology, or high-cost treatment authorizations.

4. Experience using Epic and utilization management software platforms.

1. Performs physical assessments of patients, including triage duties and advises on treatment or course of action.
2. Identifies and evaluates nursing services problems and develops and implements appropriate programs and services, including assessing staffing needs and arranging coverage as needed.
3. Develops, implements, and manages nursing care plans in collaboration with physicians.
4. Instructs patients and families in proper…