RN Utilization Review Coordinator

Job Overview

Novamed is seeking a full-time RN Utilization Review Coordinator to join their Case Management Department in Dallas, TX. This role requires thorough utilization reviews—prospective, concurrent, and post-discharge—to ensure proper patient status, medical necessity, and adherence to hospital policies, payer protocols, and regulations including CMS mandates. The coordinator will aid in admission status decisions, denial management, and support discharge planning, while contributing to utilization review reports and performance improvements.

Primary Duties

• Conduct detailed evaluations of medical records utilizing approved criteria from medical staff, CMS, and regulatory bodies ensuring nurse and physician documentation satisfy standards.
• Perform prospective (pre-admission and pre-op), concurrent, and retrospective utilization assessments to validate medical necessity and appropriate care levels via hospital software.
• Assess clinical documentation to determine correct admission categories such as inpatient, observation, outpatient, or outpatient in a bed, conforming to payer and hospital guidelines.
• Collaborate with clinical staff to guarantee timely and accurate medical orders and documentation supporting necessity.
• Engage with physicians on cases failing admission or stay criteria to achieve resolution.
• Submit required notifications and documentation to insurers for admissions, continued stays, and discharges promptly.
• Initiate modifications to admission status within hospital systems when necessary.
• Identify and manage denials linked to admission status, care level, length of stay, and medical necessity; draft and file appeal letters using clinical judgment and guidelines.
• Partner with clinicians and leadership to obtain supporting documentation for appeals and monitor appeal outcomes to inform educational feedback and reduce denials.
• Assist in discharge planning by working with case management, advocating for patients, and coordinating with healthcare teams and families to facilitate informed decision-making and smooth transitions.
• Address discharge barriers including equipment, home services, medications, and therapy requirements, while promoting patient and family education.
• Transfer Continuity of Care Documents to post-acute providers as appropriate.
• Monitor and analyze extended hospital stays and delays; investigate causative factors and collaborate with teams to resolve issues.
• Support data gathering and analysis for utilization review reports, participate in audits and surveys, and report trends related to resource utilization.
• Provide training on utilization review processes and medical necessity concepts.
• Maintain professionalism, ethical conduct, and uphold hospital mission and values through actions and communication.
• Perform additional duties assigned.

Qualifications

• Preferred education: Bachelor of Science in Nursing.
• Active Registered Nurse license for Texas and current CPR certification required; Case Management Certification(s) preferred.
• Minimum of five years' experience involving Case Management, Discharge Planning, and Utilization Review.