Lead Utilization Review, RN
Core
Lead Utilization Review RN conducts medical necessity reviews, monitors resource utilization, manages denials, and facilitates discharge planning to ensure appropriate patient care and financial integrity.
Role type
Lead Utilization Review Registered Nurse (Healthcare Operations)
Builds
Patient care delivery system and revenue cycle outcomes
Domain
Healthcare / Revenue Cycle Management
Required skills
Medical necessity determination, Resource utilization analysis, Denial management, Discharge planning, Clinical review criteria application, Physician collaboration, Regulatory compliance, Data recording for statistical entry
Preferred skills
None stated
Technologies
ConnectCare, ADT work queues
Responsibilities
Conduct daily medical necessity reviews for admissions and continued stays; Identify potential over/under utilization of services and initiate physician advisor referrals; Coordinate appeal processes and monitor denial trends; Evaluate discharge planning needs and refer to care teams; Collaborate with physicians, nurses, and coding professionals to ensure accurate medical record documentation; Record data for statistical entry and CMS indicators.
Seniority
Lead, hands-on IC