RN, Utilization Management
Core
Review clinical documentation and determine appropriate levels of care to support medical necessity and patient care services.
Role type
Utilization Management Registered Nurse
Builds
Patient care authorization workflows and regulatory compliance reports
Domain
Healthcare administration / Utilization Management
Deliverable
client delivery
Required skills
Clinical documentation review, Evidence-based criteria application, Regulatory compliance, Level of care determination, Denial and appeal management, Database querying
Preferred skills
Interqual system proficiency, SharePoint usage, Clinical documentation improvement (CDI), Discharge planning coordination
Technologies
Interqual, SharePoint, eRecord, ePARC, Cobius
Responsibilities
Conduct initial and concurrent reviews of clinical documentation; Determine level of care per regulatory requirements; Collaborate with payers for service authorization; Monitor UM hold bills and unplanned readmission reports; Support discharge appeal processes; Document according to regulatory guidelines and UM protocols.
Seniority
Mid-level, hands-on IC