RN - Utilization Review - Utilization Review

RN Utilization Review role accountable for performing prospective, concurrent, retrospective, and denial management utilization reviews for designated patient case loads by applying clinical protocols and medical necessity criteria; communicates quality-of-care issues identified in the utilization management process to the manager and collaborates with the healthcare team to ensure appropriate level of care, discharge planning, and adherence to reimbursement requirements. Responsibilities include collecting and reporting data on case mix, length of stay, costs, and utilization; applying clinical appropriateness criteria to monitor admissions and stays; and coordinating with third-party payers and physicians to support timely, high-quality patient care and efficient resource use. Requires RN license, inpatient nursing experience, and knowledge of medical procedures/codes (ICD-10, CPT, DSM-IV), with strong communication, data gathering, and analysis skills for quality improvement and patient safety.