Clinical Utilization Review Nurse II (Per Diem, Variable)

Job description

At NorthBay Health the Clinical Utilization Review Nurse II (URN) is an experienced registered nurse who prospectively and concurrently evaluates appropriateness of inpatient and observation services based on clinical documentation, evidence-based guidelines and insurance benefits, and communicates required clinical information to payers in accordance with contractual and regulatory obligations. The Level II URN serves as a clinical resource to physicians/providers by providing education related to medical necessity, utilization review and payer requirements. PRIMARY JOB DUTIES: Perform comprehensive admission and continued-stay reviews for inpatient and observation cases using facility-approved criteria and payer rules. Ensure utilization review documentation is accurate, timely and audit-ready, clearly reflecting clinical facts, criteria application and rationale. Identify opportunities for alternative levels of care when criteria are not met. Identify short-stay risk, disputed status and medical necessity concerns and escalate to Physician Advisor or leadership as indicated. Oversee and ensure the Daily Review Tracker, Ambulatory Surgery list and Observation-to-Inpatient list ar...