Position: RN Utilization Review Nurse
Location: Atlanta, GA (Onsite)
Pay Rate: Best in Market
Schedule: 8:00 AM – 4:30 PM EST
Contract Duration: 13 Weeks (Potential for Extension)
Key Responsibilities
- Perform concurrent, prospective, and retrospective utilization reviews for inpatient and observation patients.
- Evaluate medical necessity using InterQual, MCG (Milliman), and evidence-based clinical guidelines.
- Review admissions, continued stays, and level-of-care determinations.
- Collaborate with physicians, case managers, social workers, and multidisciplinary teams to optimize patient outcomes.
- Coordinate timely authorizations, payer communications, and clinical documentation submissions.
- Identify opportunities for appropriate level of care, discharge planning, and care transitions.
- Monitor length of stay, avoidable days, and utilization trends.
- Participate in denial prevention, appeals, and peer-to-peer review processes.
- Maintain accurate and timely documentation within the Electronic Medical Record (EMR).
- Ensure compliance with CMS, Medicare, Medicaid, commercial payer requirements, and hospital policies.
- Assist with quality improvement initiatives, utilization management projects, and regulatory audits.
- Educate physicians and clinical staff regarding utilization review guidelines and payer requirements.
Required Qualifications:
- Current unrestricted Registered Nurse (RN) License.
- BSN preferred.
- Minimum 3 years of Utilization Review and/or Case Management experience in an acute care hospital or managed care setting.
- Experience performing concurrent and prospective utilization review