Utilization Review RN

Job Summary

You will play a pivotal role in optimizing healthcare delivery by ensuring medical necessity and appropriate patient status throughout the hospitalization journey. You will serve as a clinical expert, collaborating with attending physicians, consultants, and care coordination teams to apply evidence-based guidelines—such as MCG or InterQual—to facilitate seamless patient care transitions.

Responsibilities

• Serve as a clinical expert, collaborating with attending physicians, consultants, and care coordination teams to apply evidence-based guidelines—such as MCG or InterQual—to facilitate seamless patient care transitions.
• Perform comprehensive admission and concurrent stay reviews to validate the clinical necessity of care, ensuring every patient interaction is documented with precision.
• Engage in proactive denial prevention strategies, coordinate peer-to-peer reviews between providers and insurance payers, and communicate critical status updates to stakeholders.
• Balancing clinical data analysis with professional communication, ensure our facility remains compliant with regulatory agencies and Joint Commission standards while supporting the overall progression of care for our diverse patient population.

Required Job Requirements

• Graduate of an accredited school of nursing and 1-3 years Minimum two (2) years of acute hospital clinical experience, upon hire or Masters
• Other In Case Management or Nursing field in lieu of 1 year experience, upon hire
• Registered Nurse: NE, upon hire or Registered Nurse: IA, upon hire
• Preferred Bachelors Of Science BSN in Nursing or related healthcare field and 4-6 years Five years of nursing experience, upon hire
• Certified Case Manager, upon hire
• Accredited Case Manager, upon hire

Where You'll Work

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.

Pay Range

$33.51 - $48.58 /hour