Job Summary
The Registered Nurse conducts clinical medical record reviews to support appropriate utilization, patient status, and reimbursement. Working with hospital teams and physicians, this role promotes accurate documentation, addresses denials, and helps ensure care decisions align with review plans, regulatory standards, and insurance requirements.
Responsibilities
- Review clinical charts for compliance with utilization review plans, state and federal regulations, and payer requirements.
- Partner with hospital staff and physicians to strengthen clinical documentation and support appropriate patient status decisions.
- Assist with denial management and work to help secure accurate reimbursement.
- Apply relevant clinical criteria when evaluating medical necessity and resource use.
Qualifications
- Current Registered Nurse license in the State of Nevada.
- At least one year of experience in case management or utilization management.
- Bachelor’s degree in Nursing preferred.
- Knowledge of InterQual or McKesson criteria and medical coding.
