About This Role
This nursing role involves conducting admission and continued stay reviews to ensure appropriate utilization of hospital resources and compliance with medical necessity criteria, payer requirements, regulatory standards, and organizational policies. The Utilization Review Nurse works collaboratively with various healthcare teams to facilitate appropriate patient status determinations and optimize reimbursement while supporting quality patient care.
Responsibilities
- Perform hospital admission reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient)
- Conduct continued stay reviews using approved clinical criteria and guidelines
- Evaluate clinical documentation for accuracy, completeness, and compliance with payer and regulatory requirements
- Apply evidence-based criteria such as InterQual® and/or MCG®
- Communicate review findings and recommendations to physicians, case management staff, and leadership
- Collaborate with Physician Advisors regarding complex cases or cases not supported by criteria
- Assist with denial prevention activities and accurate documentation
- Perform other duties as assigned
Requirements
- Graduate of an accredited school of nursing
- Current, unrestricted Registered Nurse (RN) license
- Minimum five (5) years of acute care nursing experience in a hospital setting
- Minimum two (2) years of recent hospital-based utilization review experience
- Experience with acute admission reviews and continued stay reviews
- Proficient in multiple Electronic Health Records and case management systems
- Strong communication skills, both verbally and in writing
- Ability to thrive in a fast-paced environment and adapt to frequent changing business needs
- Ability to work independently, needing minimal supervision
Nice to have:
- Bachelor’s of Science in Nursing (BSN)
- Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC)
Important Details
- Schedule: Full-time employees may be scheduled for 8-, 10-, or 12-hour shifts based on operational needs and mutual scheduling agreements; employees are expected to work every other weekend as required; three (3) of the six (6) company-recognized holidays will be assigned annually based on departmental and business needs
- Work schedules: published one month in advance; requests for vacation, time off, or schedule accommodations must be submitted at least thirty (30) days before the schedule is finalized (e.g., requests for the August schedule must be submitted by June 30)
