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