Utilization Review RN

Inspired by faith. Driven by innovation. Powered by humankindness. CHI Health, now part of CommonSpirit Health, is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 137 hospital-based locations, in addition to its home-based services and virtual care offerings. CommonSpirit has more than 157,000 employees, 45,000 nurses and 25,000 physicians and advanced practice providers across 24 states and contributes more than $4.2 billion annually in charity care, community benefits and unreimbursed government programs. Together with our patients, physicians, partners, and communities, we are creating a more just, equitable, and innovative healthcare delivery system.

Are you a skilled and experienced Utilization Review Specialist looking for a rewarding opportunity to impact patient care and optimize hospital resources? Join our dynamic team and play a crucial role in ensuring appropriate admission status and continued stay authorization for our patients. This position offers the flexibility to work remotely with proven Utilization Review experience. Medical Coding experience is a plus!

As our Utilization Review RN, you will be responsible for conducting comprehensive reviews of medical records using evidence-based guidelines and critical thinking to determine the medical necessity of inpatient services. You will collaborate closely with attending physicians, consultants, Care Coordination staff, and Concurrent Denial RNs to prevent denials and optimize patient outcomes.

Key Responsibilities:

• Perform admission, concurrent, and post-discharge reviews to ensure adherence to Utilization Review guidelines and appropriate patient status determination.
• Collaborate with Patient Access to verify payer sources and obtain necessary inpatient authorizations from insurance providers.
• Identify and address deficiencies in patient status orders, communicating effectively with providers to ensure accuracy.
• Engage with Denials RNs and revenue cycle vendors to implement denial prevention strategies.
• Ensure compliance with hospital policies, regulatory agencies (e.g., The Joint Commission), and payer-defined criteria.
• Facilitate Peer-to-Peer reviews between hospital providers and insurance providers, when necessary.
• Communicate review outcomes and necessary notifications to physicians, payers, Care Coordinators, and other stakeholders.
• Engage the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Required

• Graduate of an accredited school of nursing
• Utilization Review experience required
• Minimum two (2) years of acute hospital clinical  experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• Coding experience preferred