RN Utilization Review

Cone Health

Job Location

Reidsville, NC, US, 27320

Employment Type

Full Time

Job Posted On

28 July 2025

Job Overview


  • Job Category: Registered Nurses
  • Industry: Hospitals and Health Care
  • Application Deadline: 25 August 2025

Job Description

Overview:

The Utilization Review Registered Nurse is tasked with conducting admission, continued stay utilization reviews, and discharge screenings to validate the medical necessity of hospital admissions, the appropriate level of care, the continuation of stays, and the provision of supportive services. They collaborate closely with attending physicians, advanced practice providers, and Department Medical Directors to address issues related to patient status and medical necessity, adhering to departmental procedures for escalating cases to a higher level review when the criteria are unclear. The UR RN maintains active communication with physicians, nurses, revenue cycle staff, other members of the patient care team, and coding professionals to ensure the accuracy of medical record documentation reflecting the services delivered to patients and the clinical information used for profiling and outcome reporting. Oversight and evaluation of care delivery by the UR RN are essential to verify the medical necessity of care, its appropriateness for the care setting, and compliance with governmental and regulatory guidelines.

Responsibilities:

Reviews of cases commence promptly after admission, with follow-up assessments carried out continuously during the patient's hospitalization, in accordance with all relevant regulations.

Assessments are chronicled in EPIC, and patient information is transmitted securely to payers, with results communicated to pertinent medical personnel.

Refers pertinent cases promptly to the Physician Advisor and communicates efficiently with peers to secure the fulfillment of patient needs. Acts as a bridge between physicians and payors in matters related to the denial of benefits or lack of coverage.

Monitors the utilization of resources, identifies and resolves issues promptly with the healthcare team, and educates them on payer specifications, denials, and regulatory adherence.

Observes patient status permissions, notes code 44 procedures, and records days of hospitalization that could have been prevented before discharge.

Assists the healthcare team by ensuring thorough documentation is maintained in the EMR/Epic system, reflecting UR activities.

Oversees clinical and authorization paperwork to decrease denials and partners with the denials team for appeal coordination.

Tracks readmission occurrences, highlighting trends and potential scenarios to the transition of care nurse.

Undertakes supplemental duties as instructed.

Qualifications:

EDUCATION:

Required:

  • Bachelors Nursing degree

EXPERIENCE:

Required: 

  • 3 years as a Registered Nurse

LICENSURE/CERTIFICATION/REGISTRY/LISTING:REQUIRED

Required:

Registered Nurse license in North Carolina or a Compact state

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Job Overview


  • Job Category: Registered Nurses
  • Industry: Hospitals and Health Care
  • Application Deadline: 25 August 2025