USRN Associates

We are looking for experienced US Registered Nurses (USRNs) to support utilization management activities involving the review of medical necessity, appropriateness, and efficiency of healthcare services through comprehensive evaluation of clinical documentation and medical records while ensuring compliance with payer guidelines and regulatory requirements.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective reviews for inpatient and outpatient cases.
• Assess medical necessity and level of care using established clinical criteria such as InterQual or MCG guidelines.
• Review admissions, continued stays, procedures, and services for appropriateness and compliance with payer requirements.
• Collaborate with physicians, case managers, and healthcare providers to obtain additional clinical information as needed.
• Escalate complex cases to the Medical Director when required for final determination.
• Document review ...