Utility Management Nurses

Role Overview

Were seeking experienced Utility Management Nurses to support a clients healthcare product development by leveraging expertise in insurance coding and hospital revenue management workflows . This role involves collaborating with hospital systems to align medical documentation with insurance policies ensuring accurate coding and optimal reimbursement outcomes.

Key Responsibilities

• Insurance Coding & Revenue Cycle Alignment: Review audit and optimize insurance coding practices across hospital systems to ensure compliance and maximize reimbursement accuracy.

• Workflow Analysis: Evaluate existing revenue management workflows and recommend improvements tailored to clients AI-driven documentation tools.

• Clinical Data Interpretation: Translate complex clinical notes into standardized coding formats (ICD-10 CPT HCPCS) aligned with payer policies.

• Policy Matching: Assess coding accuracy against insurance guidelines and payer documentation requirements.

• Product Development Collaboration: Work closely with clients engineering and product teams to refine AI models that automate or assist with medical coding and documentation.

• Compliance & Quality Assurance: Ensure alignment with HIPAA CMS and payer-specific coding regulations.

Required Qualifications

• Licensure: Registered Nurse (RN) or equivalent clinical background.

• Experience: Minimum 35 years in medical coding clinical documentation improvement (CDI) or revenue cycle management .

• Certifications: CPC CCS or CRC certification preferred.

• Domain Expertise: Familiarity with hospital billing systems payer policy interpretation and coding audit procedures .

• Analytical Skills: Strong understanding of clinical documentation standards and payer logic.

• Tech Savvy: Comfortable working with EHR systems (Epic Cerner Meditech) and documentation review software.

Preferred Qualifications

• Experience working within hospital revenue integrity teams or insurance utilization management .

• Exposure to AI-powered healthcare documentation tools or automated coding systems .

• Ability to identify and flag edge cases or policy exceptions in automated workflows.

• Strong collaboration skills with cross-functional (engineering compliance and data) teams.

Engagement Model

• Contract / Part-time (Remote/In person) Flexible hours with collaboration during U.S. business person in San Francisco is a plus