Lead utilization review nursing and insurance authorization workflows for hospitalized patients, ensuring timely reviews, payer follow-up, and escalation of cases at risk for denial. This role focuses on acute care case management and utilization management, with close coordination across physician advisors, case management, nursing, and revenue cycle teams to support level-of-care decisions, appeals, and care progression. It also includes reviewing performance data, identifying denial trends, and building workflows and education to improve outcomes across hospitals.
Key Responsibilities
- Lead, coach, and support utilization review nurses and insurance specialists.
- Manage assignments, workflow priorities, and staff performance.
- Conduct initial and continued-stay reviews and follow up on authorizations.
- Coordinate payer communication, peer-to-peer reviews, and escalation of potentially denied cases.
- Partner with physician advisors and care teams on level-of-care questions and clinical appeals.
- Analyze denial, appeal, authorization, and utilization review data to identify trends and corrective actions.
- Work with case management, medical, nursing, and revenue cycle leaders to remove barriers to care progression.
- Develop workflows, education, and tools in response to performance gaps, payer requirements, and regulatory changes.
Required
- Graduate of an accredited school of nursing.
- Current Registered Nurse license in the applicable state.
- Experience in acute care case management or utilization review.
- Leadership experience in an acute care setting.
- Strong clinical judgment, communication, data analysis, and team leadership skills.
Preferred
- Bachelor’s degree in nursing or advanced degree in business or health care administration.
- ACM-RN or CCM certification.
- Experience with payer authorizations, clinical denials and appeals, and physician advisor workflows.
- Case management training through a professional organization.
Benefits & Perks
- Full-time day schedule.
- Medical, dental, vision, and prescription coverage eligibility for team members working 22.5 hours per week or more.
- Life and AD&D insurance, with short-term and long-term disability coverage options.
- 403(b) retirement plan with employer match and additional non-elective contribution.
- PTO and paid sick leave.
- Tuition assistance, advancement, and academic advising.
- Parental, adoption, and surrogacy leave.
- Backup and on-site childcare, EAP, fertility benefits, and healthy pregnancy program.