Utilization Review Nurse RN

Role Overview

The Utilization Review Nurse RN conducts initial, concurrent, and retrospective reviews of medical records to evaluate clinical, financial, and resource utilization. This role involves coordinating care to reduce avoidable delays and denials of payment by providing relevant clinical information to third-party payers. The nurse reviews medical records using utilization review criteria, documents assessments, and communicates with external reviewers, financial counselors, and care teams.

They monitor utilization patterns, identify potential denials, and collaborate with nurse Care Managers, Social Workers, Physician Advisors, and administrative staff to resolve payer issues, expedite appeals, and ensure optimal patient outcomes. The position also involves issuing Medicare forms and handling discharge communication when disagreements arise. The nurse supports efforts to decrease length of stay and avoid delays or denials, assisting in care coordination and documentation of actions taken.

• Current registered nurse license (Maryland license or eligibility)
• Associate’s Degree in Nursing; BSN or higher preferred
• Minimum of 3 years of related experience

This part-time role requires weekend shifts, with responsibilities centered on utilization management, payer communication, and care coordination to promote efficient patient care and resource use.