Utilization Review Registered Nurse

Job Overview

The Utilization Review RN is responsible for utilization management and review for prospective, concurrent, or retrospective cases. The role functions within a multidisciplinary team including physicians, social workers, discharge planning assistants, and payers, evaluating medical appropriateness of inpatient and outpatient services per guidelines and benefit determination.

• Conduct prospective, concurrent, and retrospective utilization reviews for inpatient services, observation services, and specific outpatient service requests.
• Determine medical appropriateness of inpatient and outpatient services by evaluating medical guidelines and benefit determinations.
• Collaborate with attending and consulting physicians to facilitate efficient transitions during hospitalization.
• Work with the multidisciplinary team to coordinate care and ensure reimbursement aligns with payer contracts and efficient resource use.
• Use medical necessity criteria to assess level and setting of care, assist in denial and appeals, evaluate quality, and identify potential risk management issues.
• Participate in all patient safety initiatives relevant to the position.
• Maintain professional rapport with providers, patients/families, and internal customers.
• Train and educate new UM staff nurses and new RN Care Coordinators on job competency and technical instruction.
• Advocate for appropriate placement of patients to secure correct remuneration.
• Utilize clinical application systems, utilization review systems, and business support applications.

• Licensed Registered Nurse in the State of Virginia (or eligible).
• Current RN licensure in Virginia.
• Minimum of three (3) years of nursing experience in an acute care setting.
• Completion of 15 continuing education units per year.
• Proficiency in Milliman Care Guidelines (MCG) or Inter Qual criteria for medical necessity, setting and level of care, and concurrent patient management.

• One (1) year of Care Coordination experience.
• Clinical experience with specialty patient populations.
• Two (2) to Four (4) years of recent experience in Utilization Review or Utilization Management at a health plan or managed care organization (HMO/TPA/IPA/etc.).
• Master’s Degree in Nursing or a healthcare-related field from an accredited program.
• Case Management Certification.

• Ability to flex the schedule as needed to meet department demands.
• Physical lifting capacity of 20-50 lbs.; prolonged sitting; repetitive motion.
• Strong recall, reasoning, problem solving, hearing, speaking, writing, reading, logical thinking.
• Ability to handle multiple priorities, frequent customer interactions, and adapt to frequent change.

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.