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The Utilization Review RN performs admission and continued stay utilization reviews and discharge screening to assure the medical necessity of hospital admission, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services. Collaborates with attending physicians, advanced practice providers, and/or Department Medical Directors concerning status and/or medical necessity issues. Follows departmental policy to escalate cases to second level review when criteria is in question. The UR RN consistently interacts with physicians, nurses, revenue cycle services, other patient caregivers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patient and the clinical information utilized in profiling and reporting outcomes is completed. Monitors and evaluates care to ensure care is medically necessary, provided in the appropriate setting, and generated according to governmental and regulatory agency standards. Talent Pool: Nursing |
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Conducts initial case reviews within 24 hours of admission and continues reviews as long as the patient is hospitalized, following all relevant regulations.
Reviews are documented in EPIC, and clinical information is securely transmitted to carriers, with outcomes communicated to relevant medical and hospital staff.
Refers appropriate cases to the Physician Advisor promptly and communicates effectively with peers to ensure patient needs are met. Acts as a liaison between physician and payor regarding non-coverage of benefits or denials.
Oversees resource utilization, identifies and addresses issues promptly with the healthcare team, and educates them on payer requirements, denials, and regulatory compliance.
Monitors patient status authorizations, documents code 44 processes, and documents avoidable days before discharge.
Documents UR processes and supports the healthcare team by providing comprehensive documentation in the EMR/Epic.
Maintains clinical/authorization documentation to minimize denials and coordinates with the denials team on appeals.
Monitors readmissions, reporting trends and possibilities to the transition of care nurse.
Performs other duties as assigned. |
| EDUCATION: |
| Required: Bachelors Nursing degree |
| EXPERIENCE: |
| Required: 3 years as a Registered Nurse |
| LICENSURE/CERTIFICATION/REGISTRY/LISTING: |
Required:
Registered Nurse license in North Carolina or a Compact state |
Equal Opportunity Employer At Cone Health, we strive to create a welcoming atmosphere that celebrates a diverse and unique workforce. We believe in offering equal opportunities for employment to all applicants and employees, regardless of their race, religion, age, sex, sexual orientation, gender identity, veteran's status, ethnicity, national origin, disability, color, or any other characteristic protected by law. Our hiring and employment choices are based on each individual's qualifications, skills and performance. We believe that by embracing the diversity of our team, we can better serve our patients, communities and each other.
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Cone Health
Jul 15, 2025