Utilization Review Nurse - RN

About This Role

This Senior Utilization Management Nurse role involves reviewing facility claims for contract compliance, billing accuracy, medical necessity, and hospital-acquired conditions. The position requires reviewing medical records, applying clinical criteria to determine appropriate levels of care, and conducting detailed audits of hospital bills. It also involves processing claim exceptions according to facility-specific contract requirements.

Responsibilities

• Perform retrospective utilization reviews and first-level determinations using evidence-based guidelines, policies, and nationally recognized clinical criteria
• Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance
• Prepare and present cases to the Medical Director for oversight and medical necessity determinations
• Communicate determinations to providers and members in compliance with applicable regulatory and accreditation requirements
• Prepare and review member-centered documentation and correspondence reflecting clinical determinations
• Identify potential quality-of-care issues, treatment delays, and service concerns, and intervene when clinically appropriate
• Review itemized hospital bills for coding accuracy and billing logic using industry standards and applicable regulatory guidelines
• Audit claims involving medical necessity, diagnosis-related groups, stop-loss provisions, trauma, emergency services, burns, implants, neonatal intensive care, transplants, hospital-acquired conditions, and unusual billing patterns
• Triage and prioritize cases to meet required turnaround times
• Apply clinical judgment and detailed knowledge of benefit plans to support review decisions
• Communicate clearly and collaborate effectively while maintaining efficiency and accuracy

Requirements

• Current California Registered Nurse license
• At least five years of relevant professional experience
• Strong computer navigation and documentation skills
• Ability to work independently with strong motivation and work ethic
• Utilization management and retrospective clinical review
• Medical necessity and level-of-care determination
• Claims auditing and coding accuracy review
• Contract and regulatory compliance
• Clinical documentation and case presentation
• Knowledge of benefit plans and clinical guidelines
• Prioritization, communication, and collaboration

Nice to have:

• Managed care experience, including inpatient claims or concurrent review

Important Details

• All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer