The on-site Utilization Management Registered Nurse reviews patient records and care plans to assess medical necessity, patient classification, and appropriate level of care. The nurse collaborates with physicians and interdisciplinary teams, applies screening criteria, supports care progression, monitors payer and Medicare/Medicaid compliance, and helps prevent denials through timely documentation and escalation.
Responsibilities
Collaborates with physicians and interdisciplinary teams
Applies screening criteria
Monitors payer and Medicare/Medicaid compliance
Qualifications
RN licensure in applicable state
Experience in utilization management or case management preferred
Knowledge of medical necessity criteria and level of care determination