Registered Nurse - Utilization Review, PRN

About This Role

This night-shift post on the cardiac ward pairs patient care with mentoring new nurses.

Responsibilities

• Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
• Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
• Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
• Review admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review Committee
• Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
• Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
• Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
• Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
• Maintain accurate records, compile reports, and support utilization review program operations
• Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
• Support compliance with all regulatory, accreditation, and organizational standards
• Participate in committee meetings and assist in development of utilization review plans and processes

Requirements

• Graduate of an accredited Registered Nurse (RN) program; Bachelor’s Degree in Nursing preferred
• Active RN license (state-specific requirement applies)
• Minimum of 2 years of acute care nursing experience
• Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
• Solid understanding of clinical care practices, diagnoses, treatment modalities, and hospital operations
• Excellent communication skills with the ability to collaborate effectively across teams
• Strong analytical and critical thinking skills to assess clinical appropriateness and compliance
• Proficiency in computer systems and Microsoft Office applications
• Ability to manage multiple priorities in a fast-paced healthcare environment
• Flexibility to adapt to changing schedules, workflows, and departmental needs

Nice to have:

• Prior utilization review, case management, or payer review experience

Benefits

• Tuition reimbursement for all full-time and part-time colleagues starting on day one