Utilization Review Nurse - Denials & Care Level Expert

MetroHealth; Cleveland (OH); On-site; USD 70,000 - 95,000; Full time

Job summary

MetroHealth is seeking a Utilization Review Nurse to support the physician and interdisciplinary team at patient entry. You will review inpatient admission criteria and observation status, contributing to a systematic denial management process to reduce revenue loss while maintaining high-quality care.

Ideal candidates hold a Bachelor's in Nursing with an Ohio RN license and at least five years of clinical experience.

Qualifications

• Bachelor's degree in Nursing; Ohio RN license.
• Minimum five years of clinical nursing experience.
• Knowledge of medical necessity criteria for inpatient admission and observation.
• Experience with denials based on medical necessity or severity of illness.
• Strong communication, negotiation, and analytical skills.
• Familiarity with utilization management and case management.

Responsibilities

• Support physician and interdisciplinary team in patient care at entry.
• Perform initial clinical review for inpatient admission and observation.
• Collaborate to develop denial management strategies to reduce revenue loss.
• Participate in denial management to improve reimbursement and patient care alignment.
• Uphold MetroHealth System mission and standards.

Skills

Interdisciplinary teamwork

Analytical skills

Communication skills

Utilization management

Education

Bachelor's degree in Nursing

Tools

Milliman Health Management Guidelines

Job description

MetroHealth is seeking a Utilization Review Nurse to support the physician and interdisciplinary team at patient entry. You will review inpatient admission criteria and observation status, contributing to a systematic denial management process to reduce revenue loss while maintaining high-quality care.

Ideal candidates hold a Bachelor's in Nursing with an Ohio RN license and at least five years of clinical experience.