RN, Utilization Management
Core
Review clinical documentation to determine medical necessity and appropriate level of patient care using evidence-based criteria.
Role type
Utilization Management Registered Nurse
Builds
Patient care authorization decisions and denial/appeal processes
Domain
Healthcare administration / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical documentation review, regulatory compliance, care level determination, payer collaboration, denial/appeal management, clinical documentation improvement
Preferred skills
Interqual, SharePoint, eRecord, ePARC, Cobius, Bachelor's degree in Nursing (BSN), Utilization Management experience
Responsibilities
Determine level of care per regulatory requirements and provide notifications; Collaborate with payers for service authorization; Conduct initial and concurrent reviews using evidence-based criteria; Support discharge appeal process and manage denials; Document according to regulatory guidelines and UM protocols; Conduct clinical documentation improvement efforts through query process
Seniority
Mid-level, hands-on IC