RN Claims Review and Utilization Management

A  CR/UM nurse monitors and manages current inpatient care to ensure medically necessary care is provided and then evaluates healthcare claims submitted by providers to ensure medical necessity, accuracy, and compliance with MedHealth policies. The CR/UM nurse also reaches out to hospitals and specialty providers to negotiate aggressive rates.  This is done in coordination with our corporate legal, who will memorialize the approved negotiated rates. Key responsibilities include daily contact with hospitals when a MedHealth patient is an inpatient, review medical records and clinical data, coordinating with healthcare providers, and communicating with providers to reprice claims as negotiated approve or deny services. This role is crucial for controlling costs and ensuring patients receive appropriate evidence-based care. 

 

The CR/UM nurse must have a current nursing license, minimal 1 year experience in CR/UM, and thorough knowledge of medical terminology, strong knowledge of CR/UM standards, working knowledge of claims coding to ensure we aren't overbilled, and a willingness to negotiate favorable rates with community providers/hospitals.  knowledge of medical coding standards. Familiarity with claims processing, electronic medical record (EMR) systems, and utilization review platforms like InterQual or MCG is required. Strong analytical thinking, attention to detail, and effective written and verbal communication skills make someone stand out in this role. These capabilities ensure accurate and efficient patient care and subsequent claim assessments, minimizing errors and supporting fair reimbursement within regulatory and negotiated guidelines.

Work is 8am to 5pm M-F in our Oklahoma Office.  Includes a 60-minute lunch break.