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.
