About this role
The Utilization Review (UR) Nurse has a strong clinical background blended with well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Utilizes appropriate criteria and interprets the implications of clinical status and the medical treatment plan with current federal regulations/guidelines thereby expediting the billing process, payment and preventing governmental sanction.