Utilization Review RN — Care Coordination & Reimbursement

MaineGeneral Health System; Augusta (ME); On-site; USD 81,000 - 142,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

Generous paid time off

Retirement plan with employer contrib.

Tuition assistance and professional发展

Employee wellness programs

And more!

Job summary

MaineGeneral Health is seeking an experienced Utilization Review Registered Nurse (RN) to join our collaborative Utilization Review team. You’ll support appropriate patient care, navigate medical necessity and reimbursement, and work with a multidisciplinary team to coordinate care.

The role focuses on patient care coordination, utilization management, documentation, and reimbursement, with the chance to grow professionally in a supportive environment that values teamwork and continuous learning.

Qualifications

• Current Maine RN license or ability to obtain Maine licensure in a timely manner.
• Utilization Review or Care Management experience preferred.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Excellent communication and collaboration skills.
• Ability to work independently while contributing to a team.
• Knowledge of medical necessity, reimbursement guidelines, and clinical documentation preferred.

Responsibilities

• Reviews admissions and service requests for medical necessity and reimbursement criteria.
• Assists teams with issues related to medical records, pre-certifications, reimbursements and denials/appeals.
• Coordinates discharge planning needs with healthcare team.
• Monitors delays in care and prepares data to reduce length of stay and maximize reimbursement.

Skills

RN license

Utilization Review experience

Clinical assessment

Communication

Team collaboration

Independent work

Medical necessity knowledge

Job description

MaineGeneral Health is seeking an experienced Utilization Review Registered Nurse (RN) to join our collaborative Utilization Review team. You’ll support appropriate patient care, navigate medical necessity and reimbursement, and work with a multidisciplinary team to coordinate care.

The role focuses on patient care coordination, utilization management, documentation, and reimbursement, with the chance to grow professionally in a supportive environment that values teamwork and continuous learning.