RN Utilization Management Specialist

2 weeks ago


Newport News, Virginia, United States Riverside Health System Full time
Job Summary

We are seeking a skilled RN Utilization Management Specialist to join our team at Riverside Health System. This is a part-time, on-site position working 12-hour shifts in the Emergency Department at Riverside Regional Medical Center.

Key Responsibilities
  • Ensure cost-effective patient care services are delivered by monitoring and reviewing documentation for medical necessity of admission and continued stay.
  • Communicate with payers to obtain authorization for services and ensure appropriate reimbursement.
  • Provide comprehensive utilization review services in accordance with standards of excellence and facility goals.
  • Assess patient records for medical necessity using Medicare's Two Midnight Rule and MCG guidelines.
  • Accurately document justification for level of care and ensure physician orders are appropriate.
  • Manage authorizations for acute medical services and ensure correct level of care is reflected in the authorization requested.
  • Respond to requests for clinical information in a timely manner to avoid denials.
  • Collaborate with Insurance Verification department to communicate changes in level of care and coverage.
  • Address concurrent denials in a timely manner and communicate with Physician Advisors and Attending Providers as necessary.
Requirements
  • Program Graduate, Professional Nursing (Required)
  • 3-4 years Clinical nursing experience (Required)
  • Registered Nurse (RN) - State Department of Health Professions (Required)
About Riverside Health System

Riverside Health System is a leading healthcare provider in the region, dedicated to delivering high-quality patient care and services. We are committed to creating a positive and supportive work environment for our team members.



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