RN - Utilization Review

Develop and maintain effective processes for determining appropriate admission status based on regulatory and reimbursement requirements for commercial and government payers. Perform comprehensive admission, concurrent, and retrospective utilization review functions to ensure accurate data tracking, evaluation, and reporting. Interpret clinical status and medical treatment plans against federal regulations to expedite billing, payment, and prevent governmental sanctions. Actively participate in process improvement initiatives while collaborating with multiple departments and multi-disciplinary staff. Requires current knowledge of payer regulations and accreditation guidelines.