Nurse Utilization Review Specialist

State of North Carolina; North Carolina; On-site; USD 62,000 - 102,000; Full time

Job summary

State of North Carolina’s Dept of Health and Human Services, Broughton Hospital, seeks a Nurse Consultant I to join the Utilization Review team. You will conduct initial, continued stay, and retrospective reviews, prepare appeals, and work with insurers to ensure medical necessity, proper reimbursement, and regulatory compliance. A Monday–Friday 7:00 a.m.

to 4:00 p.m. schedule is typical, with occasional flexibility for training.

Qualifications

• Licensed to practice as a Registered Nurse in the State of North Carolina and one year of experience in the area of specialization.
• Two or more years of direct-care experience in a psychiatric setting.

Responsibilities

• Perform initial, continued stay, and retrospective reviews and prepare and submit appeal requests as needed.
• Ensure services are medically necessary, support optimal reimbursement, and maintain compliance with federal and state regulations, accrediting bodies, and internal policies.
• Collaborate with Medicare, Medicaid, and commercial insurers to complete timely clinical reviews.

Skills

Medical records review

Interdisciplinary collaboration

Clinical communication

Utilization Review knowledge

Education

BSN (Bachelor of Science in Nursing)

Registered Nurse license in NC

Job description

State of North Carolina’s Dept of Health and Human Services, Broughton Hospital, seeks a Nurse Consultant I to join the Utilization Review team. You will conduct initial, continued stay, and retrospective reviews, prepare appeals, and work with insurers to ensure medical necessity, proper reimbursement, and regulatory compliance. A Monday–Friday 7:00 a.m.

to 4:00 p.m. schedule is typical, with occasional flexibility for training.