Utilization Review Nurse (RN) – Full-Time, Hybrid
About the Role
The Utilization Review Nurse ensures appropriate admission status and level of care for hospitalized patients in accordance with MCG/InterQual (Indicia) criteria, CMS regulations, and Managed Care payer requirements. This role partners closely with physicians, physician advisors, case management, and payers to support timely authorizations, concurrent reviews, and discharge planning while minimizing avoidable days and ensuring regulatory compliance.
This is a full-time, hybrid position (combination of on-site and remote work based on department needs) with the ability to adapt to multiple UR roles including Observation, Inpatient Review, and Department Coordination.
Responsibilities
- Conduct initial and concurrent chart reviews to confirm admission and continued stay meet level-of-care criteria.
- Provide telephonic or electronic clinical reviews to external payers to support authorization decisions.
Requirements
- Experience in Utilization Review, Case Management, or Managed Care.
- Working knowledge of MCG/InterQual (Indicia) criteria.
- Familiarity with CMS, Medicare, Medicaid, and commercial payer regulations.
- Proficiency with Epic or similar EMR systems.
- Strong clinical judgment, communication, and documentation skills.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care.