Utilization Review Nurse - 259398

Required Skills
Current unrestricted RN license required; RN compact license preferred
Clinical nursing experience in ICU, Emergency Department, or Operating Room
Other Requirements:
Clinical & Operational Judgment: Strong clinical assessment, critical thinking, and problem-solving skills, with a proven ability to identify internal and community resources to drive optimal patient, quality, and financial outcomes.
Communication & Negotiation: Exceptional written and verbal communication skills with a track record of negotiating effectively across physicians, payers, and multidisciplinary healthcare teams.
Customer Service Focus: Unwavering commitment to delivering exceptional customer service to all stakeholders.
Time Management & Prioritization: Ability to organize complex information, prioritize competing tasks, and execute effectively in a fast-paced environment.
Autonomy & Initiative: Highly resourceful and self-motivated with the ability to work independently.
Innovation & AI Mindset: Inquisitive and open to leveraging modern technologies, including AI, to streamline workflows, eliminate operational friction, and enhance client/patient experiences.
Remote & Travel Readiness: Remote position; candidates must be willing and able to travel and work on-site at corporate, client, or temporary locations as business needs dictate.
Preferred Skills
5+ UR Nurse Experience
Pediatric nursing experience
Interqual system experience
Schedule/Shift
This role follows a 4x10 schedule, meaning you'll work four 10-hour shifts each week, providing an additional day off during the week. Team members are expected to work every other weekend as part of the regular rotation.
Available shift options include:
10:00 a.m. - 8:00 p.m.
12:00 p.m. - 10:00 p.m.
Responsibilities
Resource Utilization & Medical Necessity
Evaluate Care Appropriateness: Conduct medical necessity and level-of-care reviews (including admission, continued stay, and observation) using approved clinical criteria, whether working onsite or remotely.
Optimize Resource Usage: Utilize proactive indicators (diagnoses, cost criteria, complications) to detect potential over- or under-utilization and address barriers to patient progress.
Manage Carrier Reviews: Submit required clinical documentation to commercial carriers and the Financial Clearance Center (FCC) within one business day of admission.
Coordinate Level-of-Care Decisions: Facilitate physician advisor referrals and second-level reviews; collaborate with providers and care managers to secure necessary clinical documentation and clarify status.
Ensure Age-Specific Care: Assess patient data across all age groups and lifespans using clinical criteria, situational analysis, and departmental guidelines to prioritize reviews.
Revenue Integrity & Denial Management
Manage Appeals & Peer-to-Peer (P2P): Coordinate the P2P review process alongside physicians, the FCC, and Revenue Cycle teams, maintaining comprehensive documentation for appeal tracking.
Prevent & Track Denials: Maintain thorough documentation to minimize denial rates, log status updates and overturned days, monitor readmissions, and report emerging denial trends.
Execute Revenue Workflows: Manage assigned ConnectCare and ADT work queues to ensure seamless billing operations and compliance with CMS and revenue cycle goals.
Resolve Billing Issues: Partner with Patient Access, Financial Counselors, the FCC, and the Business Office to resolve third-party payer billing concerns and communicate non-coverage determinations.
Communication & Interdisciplinary Collaboration
Maintain Multidisciplinary Rapport: Partner closely with physicians, in-house care managers, nursing staff, and leadership to align on patient management and outcomes.
Educate Stakeholders: Train hospital and medical staff on utilization review processes, regulatory updates, and payer requirements (e.g., MS-DRGs, POA).
Adhere to Communication Protocols: Maintain professional, timely responsiveness across email, phone, and messaging tools according to FCC service-level agreements and guidelines.
Maintain Professionalism: Exhibit a calm, constructive demeanor during stressful situations or conflict resolution.
Team Engagement & Administrative Responsibilities
Support Departmental Operations: Assist peers during high-volume periods, cover coverage gaps, and accurately log statistical data within established deadlines.
Drive Process Improvement: Actively contribute to departmental quality initiatives, committee meetings, task forces, and staff development programs.
Ensure Compliance: Maintain clinical competency, professional development, and strict adherence to hospital policies, HIPAA, confidentiality standards, and patient rights.
Flexibility: Perform additional job-related duties as assigned by leadership.

Work arrangement
Yes