Utilization Review (RN) - Per Diem
About The Position
The Utilization Review (UR) RN evaluates the medical necessity, appropriateness, and efficiency of healthcare services using MCG criteria, ensuring compliance with CMS regulations and payer requirements. This role facilitates timely insurance pre-authorizations, confirms medical necessity, and helps prevent avoidable denials. The UR RN works closely with clinical teams, case management, and payers to support safe, efficient care transitions and optimize reimbursement. The UR RN also collaborates with the Revenue Cycle Director and finance teams to investigate denials, inappropriate admission order status, avoidable revenue loss, and other financial risks. Responsibilities include monitoring length of stay and avoidable days, and reporting trends and findings to the Utilization Review Committee to support regulatory compliance and continuous improvement in utilization practices.
Requirements
- Graduate of an accredited nursing program with a current Washington State Registered Nurse (RN) license or Multistate License (MSL) with Washington endorsement (maintenance required)
- Minimum of 3 years of clinical nursing experience in acute care
- Experience with evidence-based care guidelines such as InterQual or MCG
- Familiarity with CMS Conditions of Participation, commercial health insurance and managed care billing requirements
Nice To Haves
- Bachelor of Science in Nursing (BSN)
- Experience working with Cerner EHR
- Knowledge of care guidelines from MCG
- Hospital case management experience
Responsibilities
- Evaluates the medical necessity, appropriateness, and efficiency of healthcare services using MCG criteria
- Ensures compliance with CMS regulations and payer requirements
- Facilitates timely insurance pre-authorizations
- Confirms medical necessity
- Helps prevent avoidable denials
- Works closely with clinical teams, case management, and payers to support safe, efficient care transitions and optimize reimbursement
- Collaborates with the Revenue Cycle Director and finance teams to investigate denials, inappropriate admission order status, avoidable revenue loss, and other financial risks
- Monitors length of stay and avoidable days
- Reports trends and findings to the Utilization Review Committee to support regulatory compliance and continuous improvement in utilization practices
Benefits
- KVH puts ‘employee care’ high on the priority list, with health benefits like low cost medical, dental, and vision insurance and a robust employee wellness program.
- KVH offers company contribution toward your choice of medical, dental, and vision insurance coverage, including coverage available for spouses/ domestic partners, and dependent children.
- KVH believes that continuing education is critical to our mission and vision. We have implemented many educational programs such as the Medical Assistant Apprenticeship program and certification pay to encourage continuing education.
- We want our employees to know they are valued. One of the ways we show this is by quickly vesting employees, making them pension eligible after just one year of part-time status.
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What This Job Offers
Job Type
Part-time
Career Level
Mid Level
Education Level
Associate degree
