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Utilization Review Nurse

Utilization Review (UR) Nurses combine clinical and administrative experience to monitor quality control and insurance claims for patients. UR Nurses audit client cases to determine if there are any unnecessary treatments or recommended procedures that could incur gratuitous expenses. To understand whether a patient is eligible for coverage on specific treatments, a UR Nurse must analyze the condition of the patient, review his or her case, and speak with the primary care providers.

An UR Nurse is crucial to a healthcare facility because they eliminate prolonged admissions and empower patients with the information to decide between treatments or medications that are covered by their health insurance. Without the assistance of an UR Nurse, patients may end up paying out-of-pocket for visits and treatments outside of their health insurance coverage.

Job Responsibilities

  • Perform case reviews within 24 hours of patient admission
  • Review patient records to examine patient class
  • Determine incorrect patient class assignments and reassign accordingly
  • Recommend strategies to improve findings from each review
  • Facilitate communication between clinical staff and insurance companies
  • Work to solve pending claims and prevent claim denials
  • Aid in determining discharge planning and timeline

Qualifications and Skills

  • Active RN license
  • 2-5 years of clinical experience
  • Microsoft Office proficiency
  • Advanced verbal, written, and organization skills
  • Previous UR or case management experience preferred
  • Case Management Certification (CCM) preferred
  • Electronic Medical Record (EMR) experience preferred
  • BSN preferred