Utilization Review Nurse - Supervisor

Job Overview: The Utilization Review Nurse oversees the daily operational workflows of the Medicare Utilization Review team, ensuring clinical decisions align strictly with CMS guidelines and organizational policies.

Essential Responsibilities: Claims Review and DRG Oversight• Conduct retrospective clinical and claims reviews, as needed, to assess appropriateness of billing, DRG assignment, and level of care.• Support development and implementation of policies and procedures related to retrospective DRG and claims review activities.• Review inpatient admissions for appropriateness and identify opportunities for level-of-care adjustments, including downgrades from inpatient to observation status.• Collaborate with leadership and vendor partners to learn, adapt, and implement best practices related to DRG validation and claims review methodologies.• Serve as interim liaison between delegated review entities and internal operational teams to support knowledge transfer and workflow development.

Inpatient Utilization Monitoring• Monitor daily inpatient census and track admissions for medical necessity and appropriateness of care.• Review inpatient stays for continued stay appropriateness utilizing CMS guidelines, evidence-based criteria, and internal policies.• Coordinate with physician review organizations, including ProPeer, to initiate reviews when continued inpatient admission may no longer be warranted.• Support efforts to reduce avoidable outlier days and unnecessary utilization.• Review readmissions and issue clinical determinations in accordance with organizational readmission policies and procedures.

Appeals and Denial Management• Prepare clinical summaries and supporting documentation for Medicare appeals and Independent Review Entity (IRE) submissions.• Ensure appeal cases are clinically sound, well-supported, and compliant with Medicare requirements.• Participate in development and enhancement of comprehensive appeal workflows and operational processes.

• Collaborate with Medical Directors, physician reviewers, and compliance teams regarding appeal strategies and case reviews.

Clinical and Operational Support • Provide daily clinical guidance and support to Utilization Management Coordinators and UM staff.• Respond to clinical and regulatory questions related to utilization management processes and determinations.• Serve as a clinical resource for complex utilization review cases and potential DME clinical reviews.• Assist with implementation and refinement of Medicare UM operational workflows and policies.

Quality Oversight and Auditing • Conduct routine audits of ProPeer outcomes and denial language to ensure member-friendly, clinically appropriate communication.• Monitor quality and consistency of clinical review determinations and documentation.• Collaborate with leadership regarding administrative and regulatory audit findings, including timeliness and operational performance measures.• I...