Case Management, Cost Control, Discharge Plans, Health Plan, Healthcare, Healthcare Management, Insurance, Insurance Regulations, Long-Term Care, Maintain Compliance, Medical Records, Patient Assessment, Quality Assurance, Quality Management, Quality of Care, Record Keeping, Records Management, Registered Nurse (RN), Regulatory Compliance, Resource Utilization, Utilization Management
Job SummaryAn RN Utilization Management (RN UM) is a licensed Registered Nurse responsible for reviewing and evaluating the medical necessity, appropriateness, and efficiency of healthcare services. This role ensures patients receive the right level of care while optimizing resource use and maintaining compliance with healthcare regulations and payer guidelines.
Key Responsibilities- Review patient records to assess medical necessity and appropriateness of care
- Perform utilization reviews (prospective, concurrent, and retrospective)
- Collaborate with physicians, case managers, and healthcare teams to develop cost-effective care plans
- Ensure compliance with insurance guidelines, regulatory standards, and facility policies
- Coordinate with insurance providers for authorizations and continued stay approvals
- Identify opportunities to improve quality of care and reduce unnecessary costs
- Document findings and maintain accurate records in utilization management systems
- Assist with discharge planning and transitions of care
- Monitor length of stay and resource utilization
- Participate in audits and quality improvement initiatives