RN Utilization Review

• Location: Remote

• Department: Ascension Care Management Insurance - Utilization Review

• Schedule: Day Shift | PRN until 12/31/26

• #LI-Remote
  

• Comprehensive Clinical Review: Conduct prospective, concurrent, and retrospective medical necessity reviews for admissions and service requests to ensure alignment with clinical criteria and reimbursement policies.
• Complex Case Navigation: Provide high-level case management and specialized consultation for complex patient cases to optimize care delivery and resource utilization.
• Operational & Denial Support: Assist interdisciplinary teams with coding, clinical documentation accuracy, precertification, and the management of claim denials or appeals.
• Strategic Discharge Coordination: Evaluate and coordinate discharge planning requirements in collaboration with the healthcare team to ensure safe and timely patient transitions.

• Health plan or inpatient utilization experience and InterQual or MCG experience.

Licensure / Certification / Registration:

• Registered Nurse obtained prior to hire date or job transfer date required. Licensure required relevant to the state in which work is performed.

Education:

• Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire.

Preferred Experience:

• Health plan or inpatient utilization experience preferred
• InterQual or MCG experience preferred
• Minimum of 3 years nursing experience preferred
• Nursing Licensure Compact (NLC) strongly preferred