RN Utilization Review Specialist

University Medical Center; Louisville (KY); On-site; USD 70,000 - 90,000; Full time

Job summary

UofL Health is seeking a Utilization Review RN to support the Utilization Management process. You will assess medical necessity for admissions and ongoing stays, review patient records against payer guidelines, and communicate decisions to physicians and case managers.

You will coordinate with the interdisciplinary team to ensure appropriate level of care, drive efficient resource use, and educate staff on payor requirements and documentation.

Qualifications

• Licensed RN with current state licensure.
• Experience with utilization review and case management.
• Familiar with MCG criteria and payor guidelines.
• Strong communication with physicians and payors.

Responsibilities

• Conduct timely admission and concurrent utilization review for designated services.
• Certify medical necessity for admission and continued stay per guidelines.
• Communicate with payors to obtain authorizations and document approvals.
• Collaborate with care teams to ensure appropriate level of care.
• Educate physicians and staff on payor requirements and documentation.

Skills

Utilization review

Nursing

Case management

Communication

Regulatory knowledge

Education

RN license

Tools

Case Management Software

Job description

UofL Health is seeking a Utilization Review RN to support the Utilization Management process. You will assess medical necessity for admissions and ongoing stays, review patient records against payer guidelines, and communicate decisions to physicians and case managers.

You will coordinate with the interdisciplinary team to ensure appropriate level of care, drive efficient resource use, and educate staff on payor requirements and documentation.