RN - Utilization Review & Care Coordination

Overview: Join a dedicated healthcare team as a Registered Nurse specializing in Utilization Review and Coordination of Care. This role involves evaluating patient admissions and ongoing care to ensure medical necessity and appropriate treatment levels, collaborating closely with physicians and advanced practice providers.

Responsibilities: Conduct initial and concurrent utilization reviews for admitted and observation patients, ensuring compliance with regulatory and payer requirements. Partner with interdisciplinary teams to facilitate clinical guidelines and optimize treatment outcomes in a cost-effective manner. Analyze patient records to determine admission appropriateness, treatment plans, and length of stay. Maintain up-to-date knowledge of regulatory changes affecting utilization management and perform reviews accordingly. Manage denials and appeals in collaboration with management and payors, ensuring timely responses.

Education & Certification: Registered Nurse licensure is required. Certification in Case Management (CCM or ACM) is preferred.

Experience: Ideally, candidates will have three to five years of acute care nursing experience, with a background in medical/surgical or ICU settings. Experience in case management and managed care claims or reimbursement is advantageous.

Skills & Requirements: Strong clinical knowledge and understanding of nursing principles, clinical processes, and interventions. Excellent communication, negotiation, and interpersonal skills to effectively interact with diverse populations. Proficiency with computer systems including Microsoft Office and various healthcare software platforms. Ability to prioritize multiple tasks, demonstrate sound judgment, and work collaboratively with healthcare professionals at all levels. Flexibility and adaptability to change, with a positive approach to team building and respect.

Physical Demands: Some light lifting and walking may be required. The role involves extended periods of sitting and data entry.

This position serves a regional healthcare network in the Southeastern United States, providing comprehensive care across multiple facilities and specialties.