Clinical Utilization Review Specialist

1 week ago


New Bern, North Carolina, United States CarolinaEast Health System Full time
About the Role

CarolinaEast Health System is a leading healthcare provider in the Coastal Carolina region, dedicated to delivering high-quality, compassionate care to our patients. As a Utilization Review Nurse, you will play a critical role in ensuring that our patients receive the most appropriate level of care, while also optimizing our resources and improving patient outcomes.

Key Responsibilities
  • Validate medical records to ensure accuracy and completeness
  • Apply utilization review criteria and clinical knowledge to determine appropriateness of inpatient and observation services
  • Collaborate with the Utilization Review Manager and Physician Advisor to develop and implement utilization review policies and procedures
  • Communicate with patients, families, and healthcare teams to ensure seamless care transitions
  • Stay up-to-date with changing regulations, policies, and best practices in utilization review and clinical care
Requirements
  • Graduate from an accredited School of Nursing
  • Current RN license with North Carolina State Board of Nursing
  • Minimum of five years of clinical experience, preferably in insurance/payer experience or prior utilization review
  • Excellent written, oral communication, and analytical skills
  • Ability to work independently and as part of a team
  • Strong computer skills, including Microsoft Word, Excel, and other word processing software


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