Utilization Review Registered Nurse

We are seeking a dedicated and knowledgeable Utilization Review Nurse to join our healthcare team. This role is crucial in ensuring that patients receive appropriate care while adhering to established guidelines and standards. The ideal candidate will possess a strong clinical background, excellent analytical skills, and a thorough understanding of medical documentation and coding. You will be responsible for reviewing patient records, assessing the necessity of services, and collaborating with healthcare providers to optimize patient outcomes.

Conduct comprehensive reviews of patient medical records to determine the appropriateness of care provided based on clinical guidelines. Collaborate with healthcare professionals to ensure compliance with utilization management protocols. Utilize knowledge of CPT coding, ICD-9, and ICD-10 for accurate documentation and billing processes. Engage in case management activities, including discharge planning and coordination of care across various settings such as inpatient, outpatient, home care, and hospice. Ensure adherence to HIPAA regulations while handling sensitive patient information. Participate in clinical documentation improvement initiatives to enhance the quality of medical records. Maintain familiarity with EMR and EHR systems such as Epic, Cerner, Athenahealth, and eClinicalWorks for efficient data management. Stay updated on NCQA standards and best practices in utilization review and managed care.