DC Licensed Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse (Remote) to conduct clinical chart reviews and ensure compliance with medical necessity and reimbursement policies.

Key Responsibilities

• Conduct timely clinical chart reviews and communicate effectively with third-party payers
• Review admission service requests for medical necessity and compliance with reimbursement policy criteria
• Serve as an educational resource regarding utilization review and promote quality care through resource utilization reviews

Required Qualifications and Education

• 3-5 years of experience in acute care case management or utilization management activities
• Knowledge of InterQual/Milliman criteria and CMS guidelines
• Current knowledge/certification in utilization management/case management
• RN-BSN preferred; RN-AA acceptable
• DC License or MD License required if assigned to specific locations