Utilization Review Nurse

Health Business Solutions; Pasig; On-site; PHP 480,000 - 600,000; Full time

Benefits offered by this job

Competitive salary

Healthcare benefits

Professional development

Collaborative work environment

Advancement opportunities

Work-life balance

Job summary

Mynimo, Inc. is seeking an experienced Utilization Review Nurse to support client healthcare facilities by conducting clinical assessments and coordinating patient care. The role emphasizes utilization management, documentation improvement, and compliance with healthcare regulations.

The UR Nurse will collaborate with interdisciplinary teams to ensure appropriate admission decisions, length of stay, and cost-effective care, while contributing to revenue cycle efficiency and accurate coding.

Qualifications

• RN licensure required; USRN multi-state license preferred.
• BSN degree preferred.
• Case management certification a plus.
• Minimum of 3 years clinical nursing experience.
• Strong revenue cycle management and healthcare reimbursement knowledge.
• 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.
• Commitment to maintaining patient confidentiality and ethical standards.

Responsibilities

• Conduct comprehensive clinical assessments of medical records to ensure appropriate care.
• Coordinate patient care with interdisciplinary teams to optimize cost-effective outcomes.
• Support revenue cycle processes, including coding and documentation improvement.
• Apply utilization review criteria to admissions, stays, and 23-hour observations.
• Identify opportunities to improve clinical documentation for proper reimbursement.
• Analyze clinical and financial data to identify trends and cost-saving opportunities.
• Ensure compliance with healthcare regulations and industry standards.

Skills

USRN multi-state license

BSN

Case Management Certification

3+ years nursing experience

Revenue cycle knowledge

Medical coding proficiency

Excellent communication

Independent decision making

Analytical skills

Healthcare IT proficiency

Education

BSN preferred

Case Management Certification (CCM) a plus

Tools

EMR/EHR systems

Medical coding software

Job description

UTILIZATION REVIEW NURSE

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:

   • Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

   • Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

   • Support Utilization Review Coordinator team members on cases escalated for level of care determinations

   • Screen cases for Physician Advisor review

   • Collaborate with insurance companies on concurrently denied and high risk for denial cases

5. Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

6. Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

7. 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 required; must hold a USRN multi-state/compact nursing license.

• 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