Job Description
LifeBridge Health, Inc. seeks a Utilization Review Nurse RN to evaluate medical necessity, level of care, and length of stay for hospitalized and ambulatory patients. The nurse reviews clinical documentation using InterQual/MCG and payer guidelines, collaborates with physicians and care teams, and communicates with insurers to obtain authorizations and prevent denials. Responsibilities include concurrent and retrospective review, documentation clarification, and escalation of complex cases. The role supports safe, cost-effective care, regulatory compliance, and optimal patient outcomes in a mission-driven, community-focused health system with strong opportunities for growth.
Responsibilities
- Perform concurrent and retrospective utilization review for inpatient and outpatient cases
- Apply Inter
- Qual/MCG and payer criteria to assess medical necessity and level of care
- Collaborate with physicians, nursing, case management, and ancillary teams to align care plans
- Communicate with insurance payers to obtain and maintain authorizations and prevent denials
- Clarify and improve clinical documentation to support accurate status and reimbursement
- Identify and escalate complex, at-risk, or delayed cases to leadership as needed
- Ensure compliance with CMS, regulatory, and organizational utilization management policies
- Analyze utilization trends and support performance improvement initiatives
- Educate providers and staff on utilization review processes and medical necessity criteria
- Support safe, efficient discharge planning in coordination with case management and social work
Required Skills
- Utilization review
- Clinical assessment
- Medical necessity criteria (Inter
- Qual/MCG)
- Care coordination
- Health insurance and payer rules
- EMR documentation
- Data analysis and reporting
- Regulatory compliance (CMS, Joint Commission)
- Communication and negotiation
- Time management
