Utilization Review Nurse
Core
Conducts concurrent and retrospective utilization reviews to ensure medical necessity and compliance with regulatory guidelines, expediting care delivery and managing avoidable delays for patients.
Role type
Utilization Review Nurse (Clinical Care Management)
Builds
Utilization management decisions and care coordination for hospital patients
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Utilization review criteria application, clinical scenario analysis, regulatory compliance knowledge, conflict management, data collection and reporting, age-specific patient assessment
Preferred skills
Experience in quality management, knowledge of community resources, Microsoft Office proficiency
Technologies
Microsoft Office (Excel, Outlook, PowerPoint, Word)
Responsibilities
Document utilization review activity per department standards; communicate with healthcare teams to expedite care delivery; collaborate with physicians and treatment teams on plan of care; provide clinical updates to payers and manage denial activity; serve as an educator on admission status and acute care criteria.
Seniority
Mid-level, hands-on IC