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.
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.