Utilization Review Nurse-RN

About This Role

Review and evaluate clinical information and documentation for utilization review, applying clinical criteria and policies in line with regulatory and accreditation requirements. This role independently coordinates clinical resolutions.

Responsibilities

• Review clinical information and documentation for utilization review
• Interpret data from clinical records to apply appropriate clinical criteria and policies
• Coordinate clinical resolution with internal/external clinician support
• Evaluate potential quality of care issues based on clinical policies and benefit determinations
• Determine compliance with clinical policy, regulatory, and accreditation guidelines
• Apply regulatory and accreditation standards to assure activities are processed within guidelines
• Condense complex information into a clear and precise clinical picture
• Report audit or clinical findings to appropriate staff for follow-up

Requirements

• 3 years of clinical experience
• Active and unrestricted RN license in Ohio or a compact state

Qualifications

• Associate degree in nursing
• 3 years of clinical experience

Nice to Have

• Managed Care/Medicare experience

Benefits