RN, Utilization Management
Core
Review clinical documentation and determine level of care to support medical necessity and appropriate patient care services.
Role type
Utilization Management Registered Nurse
Builds
Patient care authorization decisions and care level determinations
Domain
Healthcare / Utilization Management
Required skills
Clinical documentation review, Evidence-based criteria application, Regulatory compliance, Interqual system proficiency, Discharge appeal management, Clinical documentation improvement
Preferred skills
Bachelor's degree in Nursing (BSN), Prior Utilization Management experience, SharePoint, eRecord, ePARC, Cobius
Responsibilities
Determine level of care per regulatory requirements; Collaborate with payers to ensure service authorization; Conduct initial and concurrent reviews using Interqual; Support discharge appeal process; Document according to regulatory guidelines; Conduct clinical documentation improvement efforts.
Seniority
Mid-level, hands-on IC