RN Utilization Review II-Behavioral Health

United States

Utilization review nurse is responsible for the day to day coordination of admission criteria as it relates to healthcare needs of the patient and organization. Including knowledge of regulatory and compliance with Medicare, Medicaid and other insurance payors. This team member will communicate with a variety of clinical discipline, commercial payers, patient access, patient financial services, physician advisor and other staff members.

• Provides, initial, concurrent and retrospective reviews if assigned patients for severity of illness and intensity of service
• Demonstrates the ability to interpret Inter Qual and Milliman and Roberts criteria to ensure the patients meet admission and continued stay criteria
• Provides accurate and complete account authorization and details in plan notes
• Performs admission review on the following business day of patient's admission
• Involves the Physician Advisor as needed when physician-to-physician interaction is required to achieve appropriate clinical utilization for the patient
• Collaboratively works with the Physician Advisor to facilitate all aspects of the utilization management plan
• Serve as a liaison to patient accounting, patients access as it relates to authorizations and claims
• Demonstrates ability to communicate effectively with internal and external customers
• Demonstrates commitment toward customer satisfaction and patient advocacy
• Maintains confidentiality of patient/physician/and other team members as well as maintaining compliance with all federal/state guidelines and regulations
• Achieves budget length of stay (LOS) goal
• May perform other duties as assigned or requested and job specification can be modified or updated at any time

• Required
  
  Education:
  
  Graduate of an accredited Nursing Program
• Preferred Education:
  
  Bachelors of Science Degree in Nursing (BSN)
• Required Experience:
  
  Three (3) years of experience in acute care nursing. Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines
• Required Certifications and Licensures:
  Hold a current, active license as a registered nurse in Virginia or hold a current multistate/compact license. Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.
• Preferred Certifications and Licensures: ACMA Certification

• Job Identification 19710
• Job Category Nursing Professional
• Posting Date 02/04/2026, 02:14 PM
• Locations 3300 Rivermont, Lynchburg, VA, 24503, US