Utilization Review Nurse: Optimize Hospital Care Outcomes

MCS Puerto Rico; San Juan (PR); On-site; USD 48,000 - 68,000; Full time

Job summary

MCS Puerto Rico in San Juan is seeking a registered nurse to evaluate utilization in clinical records and hospital facilities, performing concurrent and retrospective reviews and coordinating with Case Management and other departments.

The role requires a Bachelor's in Nursing, at least one year of clinical experience, and current Puerto Rico nursing license and driver's license; Spanish and English proficiency are required.

Qualifications

• Bachelor's Degree in Nursing is required.
• At least 1 year of experience in a clinical area and reviewing hospital utilization.
• Nurse license and Puerto Rico nursing professionals license/registration required.
• Driver's License valid in Puerto Rico required.
• Languages: Spanish and English advanced.

Responsibilities

• Visits hospitals and health facilities to assess utilization in clinical records using guidelines and procedures.
• Performs daily audit entries and verifies closed cases in electronic systems.
• Evaluate justification of services and notify management of irregular utilization patterns.
• Identify and report cases with potential risks to other departments for alternative treatment planning.
• Identify, intervene, and suggest care alternatives to coordinate patient discharge plans.
• Participate in special projects and ensure compliance with corporate policies and CMS guidelines.

Skills

Nursing

Education

Bachelor's Degree in Nursing

Job description

MCS Puerto Rico in San Juan is seeking a registered nurse to evaluate utilization in clinical records and hospital facilities, performing concurrent and retrospective reviews and coordinating with Case Management and other departments.

The role requires a Bachelor's in Nursing, at least one year of clinical experience, and current Puerto Rico nursing license and driver's license; Spanish and English proficiency are required.