Sr. Virtual Utilization Review Specialist

Responsibilities

• Conduct medical necessity reviews of admissions and continued stays
• Utilize clinical review criteria to identify potential over/under utilization of services
• Coordinate the P2P process with physicians and revenue cycle teams
• Collaborate with interdisciplinary teams to identify barriers to patient progress
• Manage denial trends and assist in recording denial updates
• Facilitate patient care through situational analysis and functional assessment
• Maintain communication with in-house care management and multidisciplinary teams

Requirements

• Current unrestricted LPN or RN license (RN compact preferred)
• Bachelor's Degree in Nursing or a related field
• Three years of nursing experience in an acute care environment preferred
• Utilization review or discharge planning experience preferred
• Strong clinical assessment and problem-solving skills
• Ability to work independently in a remote environment

Preferred Qualifications

• Recent experience or working knowledge of medical necessity review criteria
• Working knowledge of quality improvement processes
• Experience in an acute care environment

Benefits

• Bonus incentives
• Paid certifications
• Tuition reimbursement
• Comprehensive healthcare and well-being programs
• Career advancement opportunities