RN Utilization Review Specialist

Health Business Solutions LLC; Town of Florida (NY); On-site; USD 85,000 - 120,000; Full time

Job summary

Health Business Solutions LLC seeks an experienced Utilization Review Nurse in New York to provide clinical guidance, drive appropriate level of care, and support revenue cycle efficiency. You will conduct medical record assessments, coordinate care with interdisciplinary teams, apply utilization criteria, and collaborate with insurers on denials.

Requires RN license (US multi-state/compact), BSN preferred, 2+ years UR experience; CCM a plus; strong analytical and communication skills.

Qualifications

• RN licensure in the US (USRN multi-state/compact)
• BSN preferred
• CCM certification is a plus
• Minimum 3 years of clinical nursing experience (hospital/acute care)
• Minimum 2 years in Utilization Review
• Strong understanding of revenue cycle management and reimbursement
• Proficiency in medical coding and clinical documentation improvement
• Excellent communication and teamwork skills
• Ability to work independently and make sound clinical/financial decisions
• Strong analytical and problem-solving skills
• Proficient in using healthcare information systems
• Commitment to patient confidentiality and ethical standards

Responsibilities

• Clinical assessment of medical records to ensure appropriate care levels.
• Coordinate patient care with interdisciplinary teams to optimize cost and outcomes.
• Support revenue cycle processes including coding, documentation improvement, and compliance.
• Apply medical necessity screening criteria for admissions and level of care determinations.
• Review admissions, continuing stays, and 23-hour observations.
• Assist UR Coordinator on escalated cases for level of care determinations.
• Screen cases for Physician Advisor review.
• Collaborate with insurers on denials and high-risk cases.
• Identify opportunities to improve documentation for reimbursement.
• Analyze data to identify trends and cost-saving opportunities.
• Maintain compliance with healthcare regulations and policies.

Skills

Clinical assessment

Care coordination

Utilization review

Data analysis

Compliance

Medical coding

Documentation improvement

Communication

Independence

Healthcare IT

Problem solving

Education

Bachelor of Science in Nursing (BSN)

CCM certification

Tools

Healthcare information systems

Job description

Health Business Solutions LLC seeks an experienced Utilization Review Nurse in New York to provide clinical guidance, drive appropriate level of care, and support revenue cycle efficiency. You will conduct medical record assessments, coordinate care with interdisciplinary teams, apply utilization criteria, and collaborate with insurers on denials.

Requires RN license (US multi-state/compact), BSN preferred, 2+ years UR experience; CCM a plus; strong analytical and communication skills.