Utilization Review Nurse

Utilization Review Nurse 

MAIN FUNCTION: 

The Utilization Management Nurse Reviewer serves as the Subject Matter Expert for the organization for patient admission status (inpatient and observation) and works with Providers, Care Management, and the Revenue Cycle team in a consultative manner to ensure appropriate admission status.  The UM RN protects the financial interests of the organization by ensuring that the UM review cycle is successfully completed from the point of admission through and including appeal of any denials received. The UM RN is an integral part of the Revenue Cycle team by tracking and trending payer issues and reporting the same to team leaders in order to address identified concerns with payer representatives.   

REPORTS TO: Manager of Utilization & Denials and System Director of Revenue Cycle 

MUST HAVE REQUIREMENTS:

LPN or RN possessing an active Ohio or Multi State license

3-5 years clinical nursing experience in varied settings

1-3 year UM experience in an acute care setting

Experience using InterQual and/or MCG criteria

Solid working knowledge of reimbursement methodology

Strong organization, prioritization and delegation skills.

Demonstrated emotional intelligence – self-control, self-awareness, social awareness and relationship management.

Excellent oral and written communication

Ability to work independently in a fast-paced environment, meeting all deadlines.

Ability to problem solve complex, multifaceted situations.

Ability to use computers and analytical software.

PREFERRED ATTRIBUTES: 

Bachelor’s degree.

UM certification.

Strong background in Medicare/Medicaid regulations related to UM and billing compliance.

Experience using MCG Indicia tools.

POSITION EXPECTATIONS:

All expectations detailed below are considered Americans with Disabilities Act (ADA) essential.

• Follows Appropriate Service Standards
• Clinical review of 100% of acute bedded patients admitted to inpatient or observation against medical necessity criteria (InterQual or MCG) utilizing provided tools (Meditech, MCG Indicia, payer portals) and prescribed process for appropriateness of status.
  1. Clinical review includes the life cycle of the admission, starting with initial case review (ICR) through and including resolution of any claims denied for status or medical necessity.
  2. Ensures continued stay reviews are submitted timely per the payer’s requirements, and that responses from the payer include coverage for all days of the stay.
  3. Monitors submitted cases for a response from the payer in a timely manner to respond appropriately to any threatened or actual denials immediately to avoid the appeal process whenever possible.
  4. Submits reconsiderations immediately (when available) according to the prescribed process.
  5. Confers with the Physician Risk Advisor (PRA) on any concerns with current patient status, then communicates needed changes to the attending provider via provided communication tools.
  6. Fully documents all case reviews in MCG Indicia/Meditech, including all pertinent information, such as method and proof of submission of all case reviews, results of case reviews and any denials received, communication with PRA and attending providers.
  7. Facilitates Peer-to-peer opportunities between the attending provider and the payer.
• Attends the daily huddle with Care Management and PRA to keep apprised of any changes, and to contribute to the huddle as the Subject Matter Expert on status.
• Strong collaboration with Care Management, serving as the SME for utilization and status.
• Ensures that denials are identified in the prescribed manner and ensures all appeals are submitted timely to the payer.
• Adheres to department productivity standards (35-40 reviews per shift)
• Assigns submitted appeals to the UM Clerical support team member for follow-up on appeal response.
• Collaborates with the Manager of Utilization & Denials to identify opportunities for improvement through daily work processes and communicates to leadership.  
• Collaborates with the PRA, Revenue Cycle Director and Manager of Utilization & Denials for issues/concerns to submit to the quarterly UM Committee.
• Performs other duties as assigned, including but not limited to:
  1. Demonstrates professional responsibility required of a Utilization Review Nurse.
  2. Complies with all department and organization policies at all times.
  3. Maintains compliance with all state/federal guidelines and standards, as well as CMS Conditions of Participation.
  4. Demonstrates a positive attitude, openness to change and responsiveness to constructive feedback.

Revised: 10/16/25

Approved: TMMYERS