Remote Utilization Management Nurse (RN) - Inpatient Claims

Amerit Consulting; California; À distance; USD 76 000 - 90 000; Plein temps

Résumé du poste

Amerit Consulting is seeking an experienced Utilization Management Nurse (RN) in California for a remote 6-month contract. The incumbent will support inpatient utilization review, medical necessity determinations, and facility claims compliance, auditing DRG classifications and reviewing hospital bills.

The ideal candidate holds an active California RN license with at least 5 years of relevant experience, performing concurrent or post-service inpatient reviews, and communicating findings to

Qualifications

• Active California RN license.
• Minimum 5 years of relevant professional experience.
• Experience with concurrent or post-service inpatient reviews.
• Bachelor's degree or equivalent experience.

Responsabilités

• Perform retrospective utilization reviews and first-level determinations using evidence-based guidelines.
• Review inpatient facility claims for medical necessity, coding accuracy, and contract requirements.
• Conduct line-by-line audits of hospital itemized bills to identify discrepancies.
• Review complex claims involving DRG validation, trauma, NICU, transplants, and hospital-acquired conditions.
• Evaluate clinical documentation to determine appropriate levels of care.
• Prepare and present cases to Medical Directors for medical necessity determinations.

Connaissances

Clinical judgment

Analytical skills

Communication skills

Documentation skills

Formation

Bachelor's degree

Outils

EMR systems

Description du poste

Amerit Consulting is seeking an experienced Utilization Management Nurse (RN) in California for a remote 6-month contract. The incumbent will support inpatient utilization review, medical necessity determinations, and facility claims compliance, auditing DRG classifications and reviewing hospital bills.

The ideal candidate holds an active California RN license with at least 5 years of relevant experience, performing concurrent or post-service inpatient reviews, and communicating findings to