Traveling Utilization Review/Denials Nurse

Job Description

Job Summary:

The Utilization Review (UR) RN is responsible for reviewing medical records to determine the appropriate admission status and continued hospitalization. This role requires collaboration with attending physicians, consultants, second-level physician reviewers, and Care Coordination staff while utilizing evidence-based guidelines and critical thinking. The UR RN also works with Concurrent Denial RNs to identify denial root causes and implement prevention strategies. Additionally, this role supports patient access processes, insurance authorization, and compliance with regulatory requirements.

Key Responsibilities:

Utilization Review & Compliance

Conduct admission and continued stay reviews in accordance with Care Coordination Utilization Review guidelines to ensure medical necessity.

Perform admission, concurrent, and post-discharge reviews to determine appropriate patient status.

Ensure compliance with utilization review principles, hospital policies, and external regulatory agencies (Joint Commission, Peer Review Organizations, and payer-specific criteria).

Identify and address deficiencies in patient status orders, working with providers to correct them.

Ensure timely communication and follow-ups with physicians, payers, Care Coordinators, and other stakeholders regarding review outcomes.

Care Coordination & Denials Prevention

Collaborate with facility RN Care Coordinators to ensure progression of care.

Engage second-level physician reviewers (internal or external) to support appropriate status determinations.

Assist in status changes, patient notifications, and education regarding insurance requirements.

Work with Denials RN/Revenue Cycle vendors to implement denial prevention strategies.

Coordinate Peer-to-Peer reviews between hospital and insurance providers when necessary.

Documentation & Process Improvement

Establish and document a working Diagnosis-Related Group (DRG) at the time of the initial review.

Maintain accurate and complete documentation of payer communications, authorizations, and status determinations.

Participate in performance improvement teams and initiatives as required.

Ensure compliance with hospital policies, best practices, and federal/state regulations.

Complete all required education and training within established timeframes.

Qualifications & Skills:

Active RN license in the state(s) covered.

BLS certification (if working in a hospital setting).

Minimum 2 years of acute hospital utilization review experience using MCG/InterQual/Xsolis criteria.

Minimum 2 years of acute hospital nursing experience in a clinical setting.

Prior care coordination, case management, or utilization management experience in a clinical or insurance setting.

Strong understanding of managed care, payer environments, and CMS standards.

Ability to pass annual Inter-rater reliability (IRR) tests for Utilization Review.

Critical thinking, problem-solving, and professional communication skills.

Strong time management, organization, and ability to work in a fast-paced environment.

Knowledge of hospital revenue cycle processes and denial management strategies.

Why Join Us?

Competitive pay packages and benefits

Work with a highly skilled and collaborative team

Opportunity to make a meaningful impact in patient care and healthcare cost management