Registered Nurse Utilization Review

Manage admissions, case management, discharge planning, and utilization review to support quality patient care and efficient care coordination. Review admissions and service requests for medical necessity, reimbursement compliance, and utilization management, while providing case management support for complex cases. Collaborate with clinical and administrative teams to resolve issues related to coding, medical documentation, precertification, reimbursement, and claim denials or appeals. Coordinate discharge planning with interdisciplinary healthcare teams to ensure appropriate transitions of care and continuity of services. Monitor compliance with federal regulations and third-party payer utilization management requirements, while preparing utilization review reports and performance metrics as needed.