Utilization Review Nurse RN - Grace Medical Center

Conduct initial, concurrent, and retrospective chart reviews to assess clinical, financial, and resource utilization data. Interface with third-party payers by providing pertinent clinical information and entering reviews into software programs. Monitor utilization patterns, identify denial trends, and coordinate with Care Managers and Social Workers to resolve payer issues and expedite appeals. Document actions taken to avoid denials and assist in communicating discharge plans to patients and families. Collaborate with Physician Advisors to address unresolved case criteria and achieve optimal patient outcomes while decreasing length of stay.