Position Summary
The Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of post-acute care services, including inpatient rehabilitation, skilled nursing facility and long-term acute care levels of care. This role ensures alignment with evidence-based guidelines, regulatory requirements and organizational policies while promoting optimal patient outcomes and cost-effective care.
Key Responsibilities
- Conduct utilization review for post-acute care services, including: Inpatient Rehabilitation Facilities (IRF)/Acute Rehab, Skilled Nursing Facilities (SNF)/Subacute Nursing Facilities, and Long-Term Acute Care Hospitals (LTAC)
- Review clinical documentation to determine medical necessity, level of care, and length of stay using approved criteria (e.g., InterQual and internal medical policies).
- Perform: Prior authorization reviews, Concurrent reviews, and Retrospective reviews as needed
- Collaborate with providers, case managers, and interdisciplinary teams to ensure appropriate care planning and transitions of care.
- Communicate determinations (approvals, denials, modifications) clearly and timely to providers and stakeholders.
- Identify cases that require escalation to Medical Directors and participate in discussions with Medical Director when appropriate.
- Monitor ongoing cases for continued stay criteria and discharge readiness.
- Ensure compliance with: CMS guidelines, State and federal regulations, and NCQA Accreditation standards
- Document all review activities accurately in the utilization management system.
- Participate in quality improvement initiatives and audits related to utilization management and post-acute care.
Qualifications
Education:
- Active, unrestricted Registered Nurse (RN) license
- Bachelor of Science in Nursing (BSN) preferred
Experience:
- 3–5 years of clinical nursing experience required
- Previous experience in a managed care organization required
- Prior experience in utilization review, case management, or discharge planning preferred
- Strong background in post-acute care settings (IRF, SNF, LTAC) highly desirable
Knowledge & Skills:
- Familiarity with utilization review criteria (InterQual)
- Knowledge of post-acute levels of care and admission criteria
- Understanding of managed care principles and reimbursement models
- Strong clinical assessment and critical thinking skills
- Excellent communication and negotiation abilities
- Proficiency in electronic medical records and UM systems
Work Environment
- Remote within a managed care setting
- May require occasional weekend or holiday coverage
Key Competencies
- Clinical judgment and decision-making
- Attention to detail and documentation accuracy
- Time management and ability to manage multiple cases
- Collaboration and provider engagement
- Regulatory and compliance awareness
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