RN Utilization Review — Part-Time Impact & Insights

ummc; Missouri; On-site; USD 36,000 - 52,000; Part time

Job summary

RN - Utilization Review at UMMC is accountable for utilization management for a designated patient load, including prospective, concurrent, retrospective, and denial reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the utilization management process to the appropriate manager.

The role requires one year of inpatient nursing experience and a valid RN license, and is based at the Main Campus Jackson in Missouri.

Qualifications

• One year of nursing experience in an inpatient setting.
• Valid RN license.
• Knowledge of utilization review, discharge planning, case management, and managed care reimbursement.
• Strong knowledge of medical procedures, diagnoses, and procedure codes (ICD-10, CPT, DSM-IV).

Responsibilities

• Performs prospective, concurrent, retrospective, and denials reviews for individual cases.
• Assists in collecting and reporting financial and performance indicators.
• Uses data to drive decisions and implement performance improvement strategies.
• Collaborates with physicians to address issues and improve outcomes.
• Applies clinical appropriateness criteria to monitor admissions and continued stays.
• Communicates with third-party payers to facilitate reimbursement and resolve payor issues.

Skills

Utilization review

Discharge planning

Case management

ICD-10

CPT/DSM-IV

Interpersonal communication

Data reporting

Quality improvement (CQI)

Independent judgment

Education

RN license

Job description

RN - Utilization Review at UMMC is accountable for utilization management for a designated patient load, including prospective, concurrent, retrospective, and denial reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the utilization management process to the appropriate manager.

The role requires one year of inpatient nursing experience and a valid RN license, and is based at the Main Campus Jackson in Missouri.