RN Utilization Review Specialist | Case Management | Days

Regular full-time position, 80 hours every two weeks, day shift, hourly pay.

Pay

Base hiring salary range: $43.93 – $70.28 per hour. Actual salaries vary based on skills and experience. This range is one component of the total rewards/compensation package.

About the role

The RN Utilization Review Specialist conducts prospective and concurrent medical record reviews to determine medical necessity and appropriate level of care in accordance with nationally recognized criteria, CMS regulations, payer contractual requirements, and organizational policy. This role focuses exclusively on utilization management functions and serves as a clinical resource to physicians and interdisciplinary teams regarding level of care determinations, documentation requirements, and medical necessity standards to support appropriate reimbursement and optimal resource utilization.

Responsibilities

• Performs admission and continued stay reviews using approved evidence-based criteria and CMS 2MN rule, including reviewing admitting orders, history and physical documentation, clinical progress notes, and transfer requests to determine appropriate inpatient or observation status. Monitors length of stay and identifies cases at risk for medical necessity denial. Documents all determinations accurately and timely in designated utilization management systems.
• Ensures compliance with CMS Conditions of Participation, Medicare regulations, and payer-specific policies. Applies federal notification requirements such as the Hospital Issued Notice of Non-Coverage (HINN), Advanced Beneficiary Notice (ABN), Medicare Outpatient Observation Notice (MOON), Important Message from Medicare (IMM), and Condition Code 44 (CC44). Ensures physician orders and status determinations align with regulatory requirements and stays current on reimbursement and compliance updates.
• Communicates clear, concise, and timely clinical information to third-party payers to secure initial and continued stay authorizations. Submits required documentation, responds to payer inquiries, and tracks authorization status. Facilitates peer-to-peer discussions with the Physician Advisor to support denial prevention efforts, assists with appeals, communicates discharge notifications, and closes authorizations upon completion of services.
• Serves as a clinical resource to physicians and interdisciplinary team members regarding medical necessity, documentation standards, and level-of-care determinations. Collaborates with the Physician Advisor to address cases not meeting criteria and participates in escalation processes. Provides education to providers on documentation improvements to support medical necessity and reimbursement integrity.
• Identifies and documents avoidable days or delays related to medical necessity or payer requirements. Participates in performance improvement initiatives aimed at reducing denials and optimizing resource utilization. Supports tracking and reporting of utilization metrics such as denials, peer-to-peer outcomes, length-of-stay variances, and observation-to-inpatient conversions. Participates in UR team meetings and committee work as required.
• Other duties as assigned.

Requirements

• Associate’s Degree in Nursing.
• 3 years of related experience.
• Active Arizona RN License.
• Basic Life Support (BLS) certification (AHA).

About the organization

A career at Onvida Health is more than just a job. It’s an opportunity to make a difference in the lives of those in our shared community. When you join our team, you become an integral part of a thriving organization committed to improving the health and well-being of everyone in southwestern Arizona. We believe in progress with purpose, matching our commitment to innovation with dedication to kindness and integrity. We’re looking for people who approach each day with a sense of possibility, a drive to make things better, and a commitment to kindness.

Location

Yuma, Arizona, recognized by Guinness World Records as the Sunniest City on Earth, offers a welcoming, tight-knit community with access to outdoor activities like hiking, the Colorado River, and local cultural festivals. Yuma provides a balance of a fulfilling career and personal adventures, with easy access to larger cities and popular destinations.

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