The Utilization Review RN conducts chart review to determine medical necessity, appropriate level of care, and insurance coverage across initial, concurrent, and retrospective reviews. This role focuses on acute hospital utilization management, with frequent coordination around denials, appeals, discharge planning, and communication with payers and internal care teams. It is a full-time remote position within a hospital-based physician advisor and case management workflow.
Key Responsibilities
- Conduct initial, concurrent, and retrospective chart reviews using utilization review criteria.
- Provide clinical information to third-party payers and assist with certification activities as required.
- Monitor denials, identify utilization trends, and coordinate follow-up with care management, social work, and financial counseling.
- Document review findings and care coordination actions in the utilization management software system.
- Assist with patient and family communication regarding denied days and Medicare notices, including HINN and Detailed Notice of Discharge.
- Coordinate with care managers and physician advisors to support timely discharge, avoid delays, and reduce denied days.
- Identify cases that do not meet criteria and send referrals or escalations to physician advisors for review.
- Participate in expedited appeals and other unresolved payer-related issue resolution.
Required
- Current Registered Nurse license or eligibility to obtain a Maryland RN license.
- ADN required.
- 3-5 years of utilization review experience.
- Experience in an acute hospital setting preferred by the employer for this role.
Preferred
- BSN.
Benefits & Perks
- Remote work arrangement.
- Medical, dental, and vision coverage starting the first of the month after hire.
- Wellness programs and mental health support.
- 403(b) retirement plan with employer match, pension, life insurance, and disability insurance.
- Tuition reimbursement for advanced degrees and specialty certifications.
- Generous paid time off.
- Fitness discounts and free on-site parking.