Job Description
Reports To : Director of Nursing; Acute and Emergency Department FLSA Classification: Part-Time, Non-Exempt, Hourly $33.50 - $49-53 Essential Functions: The Part-Time Utilization Review Nurse is a Registered Nurse (RN) responsible for conducting utilization reviews to determine the medical necessity and appropriateness of patient admissions, continued hospital stays, and the level of care provided. This role ensures compliance with regulatory requirements and payer guidelines, proactively identifies potential barriers to discharge, and works to prevent claim denials, thereby supporting efficient patient throughput and optimal resource utilization within the hospital. Perform concurrent and retrospective utilization reviews for all patient admissions and continued stays, applying established medical necessity criteria (e.g. InterQual, Milliman Care Guidelines), and payer specific guidelines. Communicate effectively with attending physicians, residents, and other healthcare providers regarding medical necessity, documentation requirements, and alternative levels of care. Identify and address potential barriers to discharge, collaborating with the Case Management team to facilitate timely patient progression. Document all review activities, including approvals, denials, and appeals processes, accurately and thoroughly in the electronic health record (EHR) system. Assist in the preparation and submission of appeals for denied services, providing clinical rationale and supporting documentation. Stay current with Medicare, Medicaid, and commercial payer regulations, policies, and medical necessity criteria. Collaborate with the Case Management team to ensure seamless coordination between utilization review and discharge planning activities. Participate in interdisciplinary team meetings to discuss patient status, care progression, and discharge rea