Nurse Consultant - Utilization Review & Compliance

Adult Correction; North Carolina; On-site; USD 62,000 - 102,000; Full time

Job summary

Broughton Hospital, part of the North Carolina Department of Health and Human Services, seeks a detail‑oriented Nurse Consultant for the Utilization Review (UR) Department. You will perform initial, continued stay, and retrospective reviews and prepare appeal requests to ensure medical necessity and proper reimbursement.

You will collaborate with Medicare, Medicaid, and commercial insurers, support documentation quality, patient acuity, and level‑of‑care standards.

Qualifications

• Experience reviewing client medical records and charts.
• Experience collaborating with various disciplines and departments within an organization.
• Experience discussing clinical or care-related information with patients, families, and authorized representatives.
• Bachelor of Science in Nursing (BSN).
• Two or more years of direct-care experience in a psychiatric setting.

Responsibilities

• Perform initial, continued stay, and retrospective reviews.
• Prepare and submit appeal requests as needed.
• Ensure services are medically necessary and support proper reimbursement.
• Collaborate with Medicare, Medicaid, and commercial insurers on clinical reviews.
• Support data collection and reporting for the UR Department.

Skills

Medical record review

Interdisciplinary collaboration

Clinical communication

BSN

Psychiatric care experience

Education

BSN

Job description

Broughton Hospital, part of the North Carolina Department of Health and Human Services, seeks a detail‑oriented Nurse Consultant for the Utilization Review (UR) Department. You will perform initial, continued stay, and retrospective reviews and prepare appeal requests to ensure medical necessity and proper reimbursement.

You will collaborate with Medicare, Medicaid, and commercial insurers, support documentation quality, patient acuity, and level‑of‑care standards.