Utilization Management Nurse

Cherry Hill Free Clinic, Inc.; Denver (CO); On-site; USD 65,000 - 90,000; Full time

Job summary

Cherry Hill Free Clinic, Inc. is seeking a Medical Review Specialist to assess admissions and service requests for medical necessity and reimbursement compliance, determining patient status and ensuring thorough documentation.

You will support complex cases, coordinate discharge planning, and collaborate with case managers and payers to optimize care transitions and documentation accuracy.

Qualifications

• Strong clinical review skills and knowledge of reimbursement criteria.
• Ability to manage complex cases with attention to documentation.
• Effective communication and coordination with internal teams and payers.

Responsibilities

• Review admissions and service requests for medical necessity and reimbursement requirements.
• Ensure accurate patient status determination and documentation support.
• Assist with complex case support and related decision-making.
• Coordinate discharge planning and related case progression activities.
• Collaborate with case managers and communicate effectively with payers.

Skills

Clinical review

Reimbursement compliance

Case coordination

Communication with payers

Job description

Role Summary

Review admissions and service requests to determine medical necessity, reimbursement compliance, and appropriate patient status. Support complex cases by analyzing documentation and applying relevant criteria.

Key Responsibilities

• Review and evaluate admissions/service requests for medical necessity and reimbursement requirements.
• Ensure accurate patient status determination and documentation support.
• Assist with complex case support and related decision-making.
• Coordinate discharge planning and related case progression activities.
• Collaborate with case managers and communicate effectively with payers.

Qualifications & Skills

Strong clinical review skills, attention to reimbursement and compliance requirements, ability to manage complex cases, and effective communication and coordination with internal teams and payers.