Utilization Review Nurse Rn

Job Summary

We are seeking a highly motivated and experienced Utilization Review Nurse to join our team. The Utilization Review Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective utilization management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities

1. Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.
2. Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
3. Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.
4. Utilization Review:
   1. Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays
   2. Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients
   3. Support Utilization Review Coordinator team members on cases escalated for level of care determinations
   4. Screen cases for Physician Advisor review
   5. Collaborate with insurance companies on concurrently denied and high risk for denial cases

1. Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.
2. Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.
3. Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications

• Registered Nurse (RN) licensure in the state of practice.
• Bachelor of Science in Nursing (BSN) preferred.
• Case Management Certification (e.g., CCM) is a plus.
• Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.
• Strong understanding of revenue cycle management and healthcare reimbursement.
• Proficiency in medical coding and clinical documentation improvement.
• Excellent communication, interpersonal, and teamwork skills.
• Ability to work independently and make sound clinical and financial decisions.
• Strong analytical and problem-solving skills.
• Proficient in using healthcare information systems and technology.
• Commitment to maintaining patient confidentiality and ethical standards.

Benefits

• Competitive salary
• Comprehensive healthcare benefits
• Professional development and training opportunities
• Collaborative and supportive work environment
• Opportunities for advancement within the company
• Work-life balance programs

Work Context

A 100% remote work force will require very strong communication and remote relationship building skills. If you are a skilled Utilization Review Nurse who is passionate about enhancing patient care and optimizing revenue cycle processes, we encourage you to apply for this exciting opportunity with Long Tail Health Solutions. Join us in making a positive impact on the healthcare industry and helping healthcare providers thrive financially while providing top-notch patient care.

Note

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.