Registered Nurse (RN) Utilization Review

Where You Will Work

The Utilization Review RN is responsible for performing accurate and timely concurrent and retrospective reviews using established criteria to ensure appropriate utilization of healthcare resources. This role collaborates with physicians, hospital departments, and multidisciplinary teams to expedite care delivery, prevent delays, and maintain compliance with regulatory guidelines.

We're Looking For

• Registered Nurse license issued by the state (WISCONSIN) in which the team member practices.
• Bachelor's Degree in Nursing
• Requires 3 years of experience in clinical nursing, With a strong preference in utilization and/or quality management.
• Working knowledge of Microsoft Office (Excel, Outlook, PowerPoint, Word).
• Understanding of quality and acute care patient needs related to care management.
• Knowledge of Utilization Review criteria;
• Strong critical thinking skills for applying medical necessity criteria.
• Excellent analytical, communication, and interpersonal skills for interaction with patients, families, physicians, and payers.

What You Will Do

• Document utilization review activities per department and medical center standards in a timely manner.
• Perform and document concurrent and retrospective reviews based on approved criteria.
• Communicate effectively with healthcare teams, including physicians and ancillary services, to support timely care delivery.
• Collaborate with managers, medical directors, and treatment teams to address utilization issues and ensure compliance.
• Refer cases to physician advisors as needed for accurate status determination.
• Stay current on healthcare regulations, reimbursement issues, and community resources.
• Provide clinical updates to payers, coordinate denial activity, and manage avoidable delays.
• Serve as an educator and resource for staff regarding admission status, acute care criteria, and regulatory requirements.
• Develop and maintain relationships with community agencies to support patient and family needs.
• Demonstrate age-specific care knowledge and skills across the patient lifespan.

Join our team and help ensure quality, efficient care for every patient!

Your feedback matters. Every nurse’s voice is vital in shaping our culture and improving care. We value your insights and experiences because they help us grow stronger together.

Ready to Take the Next Step:

Apply Today!