Utilization Review Nurse

As a Utilization Review Nurse, you will play a pivotal role in evaluating and optimizing healthcare services by ensuring the efficient and effective utilization of resources. Your primary responsibility will involve conducting thorough reviews of patient medical records, treatment plans, and healthcare services to determine the appropriateness, necessity, and quality of care. Collaborating closely with healthcare providers, insurance companies, and other stakeholders, you will assess the utilization of medical resources to promote cost-effective and high-quality patient outcomes.

Company Overview:

For over 20 years, we've been a leading middle market revenue cycle management (RCM) vendor, providing comprehensive financial and operational solutions to health systems, physician groups, or specialty medical practices. Our mission is to improve the overall financial health of our clients by offering customized, data-driven, and tech-enabled recovery of denied claims and aged receivables. We utilize our deep expertise in revenue cycle to help transform our client's revenue cycle processes to achieve sustained reductions in denial rates.

Key Responsibilities:

1. Clinical Assessment: Conduct comprehensive clinical assessments to determine the patient's medical condition, healthcare needs, and treatment options.

2. Patient Advocacy: Serve as an advocate for patients by ensuring they receive appropriate care, coordinating with healthcare providers, and assisting in the resolution of healthcare-related issues.

3. Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.

4. Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.

5. Utilization Review: Evaluate the necessity and appropriateness of healthcare services and assist in the management of length of stay, ensuring that healthcare resources are used efficiently.

6. Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.

7. Patient Education: Educate patients and their families about healthcare options, treatment plans, and financial responsibilities, helping to promote informed decision-making.

8. Quality Assurance: Ensure the quality of care provided meets or exceeds established standards and that clinical documentation accurately reflects the patient's condition and care provided.

9. Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.

10. Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards.

Qualifications:

Registered Nurse (RN) licensure in the Philippines, USRN license preferred.

Bachelor of Science in Nursing (BSN) preferred.

Case Management Certification (e.g., CCM) is a plus.

Minimum of 2 years of clinical nursing experience, preferably in a hospital or acute care setting.

Strong understanding of revenue cycle management and healthcare reimbursement.

Proficiency in medical coding and clinical documentation improvement.

Excellent communication, interpersonal, and teamwork skills.

Ability to work independently and make sound clinical and financial decisions.

Strong analytical and problem-solving skills.

Proficient in using healthcare information systems and technology.

Commitment to maintaining patient confidentiality and ethical standards.

We offer a competitive salary and benefits package, including medical, dental, vision, and life insurance, a 401(k) plan with company match, and opportunities for professional growth and development. Join our team and contribute to our mission of empowering healthcare providers to optimize their revenue cycle and achieve financial success.

Health Business Solutions, LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.