Registered Nurse – Utilization Review | Reimbursement

Job Description

Networks Connect is conducting a search on behalf of our client, a local prominent healthcare system. We are seeking an experienced Utilization Review \ Reimbursement Nurse (RN) to join our client’s healthcare team. In this role, you’ll play a key part in ensuring accurate and timely reimbursement by reviewing medical necessity, authorizations, and denials across both Medicaid and commercial payors. Your expertise will directly support the financial sustainability of our organization while advocating for patients and providers.

This is an excellent opportunity for a registered nurse with utilization review, case management, or payor relations experience who is ready to apply both clinical knowledge and analytical skills in a dynamic healthcare environment.

Earnings

$100,000 - $125,000 salary

Duties

• Conduct comprehensive clinical reviews to support authorizations, continued stays, or appeals.
• Provide timely, well-documented appeals using evidence-based criteria (InterQual, MCG).
• Monitor payor responses to ensure timely claim payments or appropriate adjustments.
• Track, trend, and analyze authorization and denial data to identify patterns and recommend process improvements.
• Serve as a subject matter expert for reimbursement and denials within the revenue cycle.
• Collaborate with physicians, case managers, and payors to resolve treatment delays or payment issues.
• Educate staff across departments on authorization requirements and denial prevention.

Requirements

• 5 years of nursing experience, including at least 3 years in Utilization Review, Case Management, or a related area
• Strong critical thinking, problem-solving, and communication skills
• Proficiency in Microsoft Office (Excel, Access, PowerPoint)
• Exceptional documentation and business writing skills

License / Certification

• BSN required; MSN preferred
• Active RN license

Benefits

• 401(k) with employer match
• Medical, dental, and vision insurance
• Life insurance
• Paid time off & holidays
• Supportive, collaborative hospital-based environment
• Disability insurance
• Flexible spending account
• Health savings account
• Parental leave