Senior Utilization Review RN - Complex-Care Expert

Sage Clinical RCM, LLC; Saint Petersburg (FL); On-site; USD 55,000 - 90,000; Part time

Job summary

Sage Clinical RCM, LLC is seeking a Part Time Senior Utilization Review Specialist. This experienced RN will conduct concurrent and retrospective reviews of hospital services to verify medical necessity, determine level of care, and secure payer authorization.

The role acts as a clinical resource for complex cases, collaborates with physicians, care management, coding, and revenue cycle teams to reduce denials and support compliant reimbursement.

Qualifications

• Current, unrestricted RN license.
• Five or more years of acute-care hospital experience, including at least three years in utilization review, utilization management, case management, or a closely related function.
• Experience applying medical-necessity and level-of-care criteria, including concurrent review and continued-stay review.
• Working knowledge of inpatient versus observation status, payer authorization requirements, Medicare and managed-care utilization principles, and denial-prevention practices.
• Strong clinical judgment, prioritization, documentation, communication, and collaborative problem-solving skills.
• Ability to independently manage a high-volume, deadline-driven caseload while exercising sound judgment regarding escalation.

Responsibilities

• Perform concurrent and retrospective utilization review for inpatient, observation, and outpatient cases using approved criteria, payer policies, and clinical judgment.
• Apply InterQual, MCG, or client-approved criteria to support medical necessity, level of care, continued stay, and patient-status determinations.
• Obtain, submit, and track payer notifications and authorizations; communicate clinically relevant information to payer medical-management teams within required time frames.
• Identify potential medical-necessity, authorization, status, and documentation risks early and escalated appropriately to prevent avoidable denials.
• Collaborate with physicians, case management, CDI, coding, patient access, and revenue cycle partners to clarify documentation and support appropriate care progression.
• Coordinate clinical information and deadlines for peer-to-peer review or denial escalation when needed; maintain complete, accurate documentation in the designated systems.
• Serves as a member of the Utilization Review Committee-prepares reports to include utilization trends, denial patterns, extended stays, and workflow barriers; communicate actionable findings to leadership.
• Performs escalations to UR Committee members to ensure that compliance with regulations for patient status changes by providers are occurring per policy. Documents escalations and presents outcomes to UR committee.
• Serve as a senior clinical resource, providing guidance and support on complex review questions while adhering to established policies and escalation pathways.
• Participate in quality audits, education, process improvement, and other initiatives that strengthen utilization management performance.

Skills

RN license

Acute-care

Utilization review

Case management

Medical necessity

Payer authorization

Documentation

Communication

Collaboration

HIPAA compliance

Education

BSN

CCM/ACM certification

Tools

InterQual

MCG

Cerner

EHR systems

Job description

Sage Clinical RCM, LLC is seeking a Part Time Senior Utilization Review Specialist. This experienced RN will conduct concurrent and retrospective reviews of hospital services to verify medical necessity, determine level of care, and secure payer authorization.

The role acts as a clinical resource for complex cases, collaborates with physicians, care management, coding, and revenue cycle teams to reduce denials and support compliant reimbursement.