The primary responsibility of the utilization review nurse is to review medical records and prepare clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. An understanding of the severity of an array illnesses, intensity of service, and care coordination needs are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review nurse works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings.
The utilization review nurse manages all activities related to the monitoring, interpreting, and appealing of clinical denials received from third-party payers and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the nurse result in the overturning of denied claims and recovered revenue for the health care provider. Those in the position also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation.
A bachelor's degree and state licensure in the relevant jurisdiction as a registered nurse is required. Strong candidates generally have three or more years' adult or pediatric clinical experience in a hospital setting, including at least one year as a utilization review nurse. Excellent written and oral communication skills are a must, as is the ability to work and meet deadlines in a fast-paced environment. Strong computer and customer service skills are required as well.
Registered Nurse (RN), Utilization Review (UR) Tasks
- Audit and analyze patient records to ensure quality patient care and appropriateness of services.
- Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims.
- Analyze information gathered by investigation, and report findings and recommendations.
- Modify patient treatment plans as indicated by patients' responses or case history.