RN Utilization Review

Job Summary We are seeking a dedicated and experienced RN Utilization Review Specialist to join our healthcare team.In this role, you will be responsible for evaluating patient care plans, ensuring appropriate utilization of medical services, and supporting clinical documentation improvement initiatives.Your expertise will help optimize patient outcomes while maintaining compliance with healthcare regulations and standards.The ideal candidate will possess strong clinical judgment, comprehensive knowledge of healthcare coding systems, and proficiency with electronic health record (EHR) systems.Key Responsibilities: Conduct thorough reviews of medical records to assess the necessity, appropriateness, and efficiency of patient care across inpatient, outpatient, and specialized settings such as ICU, PICU, or trauma centers Collaborate with multidisciplinary teams to facilitate discharge planning, case management, and coordination of care for complex cases including hospice or home care Utilize clinical documentation to support accurate coding using ICD-10, CPT, ICD-9, and DRG classifications Ensure compliance with Medicare, NCQA standards, HIPAA regulations, and other relevant healthcare policies Review medical documentation for accuracy and completeness in accordance with hospital policies and managed care requirements Support utilization management initiatives by analyzing patient data within EMR/EHR systems such as Cerner, Epic, Athenahealth, or eClinicalWorks Participate in clinical documentation improvement programs to enhance the quality of medical records and coding accuracy Assist in identifying opportunities for cost containment without compromising patient care quality Maintain up-to-date knowledge of physiology, anatomy, medical terminology, and healthcare regulations to inform review processes Duties Perform detailed case reviews to determine medical necessity based on clinical guidelines and standards such as NCQA or hospital protocols Evaluate inpatient admissions, outpatient procedures, emergency medicine cases, or specialty services like pediatrics or primary care clinics Monitor utilization trends and prepare reports for management to support strategic decision-making Coordinate with case managers and physicians to facilitate appropriate discharge planning and transition of care Ensure timely documentation review within EMR/EHR platforms such as Cerner or Athenahealth to support billing accuracy and compliance Apply ICD-10/ICD-9 coding conventions accurately for diagnostic classification and reimbursement purposes Maintain comprehensive records of review findings in accordance with HIPAA privacy standards Participate in ongoing education related to managed care policies, hospital accreditation standards (e.g., Level I Trauma Center), and clinical best practices Contribute to quality assurance initiatives by auditing medical records against NCQA standards Experience Minimum of three years of nursing experience in acute care settings such as ICU, emergency medicine, or trauma centers; experience in Level I or Level II trauma centers preferred Proven expertise in utilization review or utilization management within hospital or managed care environments Strong background in clinical documentation improvement (CDI) programs and medical coding including ICD-10/ICD-9/CPT coding systems Familiarity with EMR/EHR systems such as Cerner, Epic, Athenahealth, or eClinicalWorks is essential Knowledge of healthcare regulations including HIPAA compliance and Medicare policies is required Experience working with diverse patient populations including pediatrics, hospice care, or outpatient services is advantageous Demonstrated ability to interpret physiology and anatomy knowledge within a clinical context for accurate review processes If you are committed to enhancing patient care through meticulous review processes combined with a passion for healthcare excellence, we encourage you to apply today.Join our team dedicated to advancing clinical documentation quality while supporting efficient resource utilization across our healthcare facilities.#Nurse2026 Pay:$67.00 - $70.00 per hour Experience: RN Utilization Review:2 years (Required) License/Certification: BLS Certification (Required) Work Location:On the road.