Utilization Review RN: Optimize Care & Reimbursement

WVU Medicine; Core (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

SYSTEM West Virginia University Health System is seeking an Utilization Review (UR) Nurse to specialize in examining medical records and developing concise clinical reviews to support authorization, reduce denials, and optimize reimbursement.

The UR Nurse applies UM principles, medical necessity knowledge, and patient status determination to perform initial and concurrent reviews for patients admitted or placed in outpatient status with observation services.

Qualifications

• Current RN license in state of service or multistate eNLC license.
• Three years of healthcare clinical experience.
• Bachelor's or ASN/Diploma in nursing; BSN progress within 3 years.

Responsibilities

• Communicate medical necessity to payor effectively.
• Review and evaluate clinical information for UM decisions.
• Ensure authorization process with patient-centered care and timelines.
• Compile concise clinical reviews from medical records.
• Collaborate with UR coordinators and physician advisors to prevent denials.
• Advocate for patient and hospital with insurers to optimize coverage.
• Document payor communications and clinical reviews timely.
• Maintain knowledge of payor requirements.
• Identify delays and coordinate with physicians for status.
• Provide orientation and training for staff ongoingly.

Skills

Communication

Interpersonal skills

Attention to detail

Medical terminology

Payer knowledge

Tact & diplomacy

Computer skills

Customer service

Education

RN license (state or eNLC)

BSN/ASN or Diploma; BSN in progress within 3 years

Job description

SYSTEM West Virginia University Health System is seeking an Utilization Review (UR) Nurse to specialize in examining medical records and developing concise clinical reviews to support authorization, reduce denials, and optimize reimbursement.

The UR Nurse applies UM principles, medical necessity knowledge, and patient status determination to perform initial and concurrent reviews for patients admitted or placed in outpatient status with observation services.