Utilization Review RN - Care Coordination & Denials Expert

3M HEALTHCARE; Richmond (VA); On-site; USD 90,000 - 120,000; Full time

Job summary

3M HEALTHCARE in Virginia seeks an Utilization Review Registered Nurse responsible for utilization management across prospective, concurrent, and retrospective cases within a multidisciplinary team. The role requires a Virginia license, at least three years in acute care, and CEU completion each year.

You will collaborate with physicians, payers, and staff to ensure appropriate care levels and reimbursement while supporting patient safety and quality initiatives.

Qualifications

• Three+ years of nursing experience in an acute care setting.
• Current Virginia RN licensure.
• Completion of 15 continuing education units per year.
• Proficiency with Milliman Care Guidelines (MCG) or InterQual criteria for medical necessity, setting and level of care.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for inpatient, observation, and select outpatient services.
• Evaluate medical necessity and determine appropriate level of care based on guidelines and benefit determinations.
• Collaborate with attending and consulting physicians to facilitate transitions during hospitalization.
• Coordinate with multidisciplinary team to ensure reimbursement aligns with payer contracts and efficient resource use.
• Use clinical criteria to assess level and setting of care, assist in denial/appeals, and participate in risk management.
• Support patient safety initiatives and maintain professional rapport with providers, patients/families, and internal customers.

Skills

Acute care nursing

Clinical assessment

Care coordination

Education

Virginia RN license

CEU 15/year

MCG/InterQual experience

Master's degree (preferred)

Job description

3M HEALTHCARE in Virginia seeks an Utilization Review Registered Nurse responsible for utilization management across prospective, concurrent, and retrospective cases within a multidisciplinary team. The role requires a Virginia license, at least three years in acute care, and CEU completion each year.

You will collaborate with physicians, payers, and staff to ensure appropriate care levels and reimbursement while supporting patient safety and quality initiatives.