Utilization Review Nurse (Medicare)

Job Overview:

The Utilization Review Nurse oversees the daily operational workflows of the Medicare Utilization Review team, ensuring clinical decisions align strictly with CMS guidelines and organizational policies.

Essential Responsibilities:

• Claims Review and DRG Oversight
• Conduct retrospective clinical and claims reviews, as needed, to assess appropriateness of billing, DRG assignment, and level of care.
• Support development and implementation of policies and procedures related to retrospective DRG and claims review activities.
• Review inpatient admissions for appropriateness and identify opportunities for level-of-care adjustments, including downgrades from inpatient to observation status.
• Collaborate with leadership and vendor partners to learn, adapt, and implement best practices related to DRG validation and claims review methodologies.
• Serve as interim liaison between delegated review entities and internal operational teams to support knowledge transfer and workflow development.

Inpatient Utilization Monitoring
• Monitor daily inpatient census and track admissions for medical necessity and appropriateness of care.
• Review inpatient stays for continued stay appropriateness utilizing CMS guidelines, evidence-based criteria, and internal policies.
• Coordinate with physician review organizations, including ProPeer, to initiate reviews when continued inpatient admission may no longer be warranted.
• Support efforts to reduce avoidable outlier days and unnecessary utilization.
• Review readmissions and issue clinical determinations in accordance with organizational readmission policies and procedures.

Appeals and Denial Management
• Prepare clinical summaries and supporting documentation for Medicare appeals and Independent Review Entity (IRE) submissions.
• Ensure appeal cases are clinically sound, well-supported, and compliant with Medicare requirements.
• Participate in development and enhancement of comprehensive appeal workflows and operational processes.

• Collaborate with Medical Directors, physician reviewers, and compliance teams regarding appeal strategies and case reviews.

Clinical and Operational Support

• Provide daily clinical guidance and support to Utilization Management Coordinators and UM staff.
• Respond to clinical and regulatory questions related to utilization management processes and determinations.
• Serve as a clinical resource for complex utilization review cases and potential DME clinical reviews.
• Assist with implementation and refinement of Medicare UM operational workflows and policies.

Quality Oversight and Auditing

• Conduct routine audits of ProPeer outcomes and denial language to ensure member-friendly, clinically appropriate communication.
• Monitor quality and consistency of clinical review determinations and documentation.
• Collaborate with leadership regarding administrative and regulatory audit findings, including timeliness and operational performance measures.
• Identify opportunities for process improvement, staff education, and regulatory compliance enhancement.

Specific Knowledge, Skills, and Abilities:

· Valid New York State, unrestricted, RN license

· Bachelor’s Degree (BSN) preferred

· Medicare experience (required)

Not a remote position

Benefits:

• Medical, dental, and vision insurance
• Generous PTO package
• Multiple floating holidays
• 401 (K) with employer contribution