Utilization Review Nurse

As our Utilization Management Nurse, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision-making, regulatory compliance, and responsible resource utilization.

Every day, you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria. 

To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow.

Skills needed:

Knowledge of federal, state and managed care rules and regulations including CMS and AHCCCS. Working knowledge with INTERQUAL or Milliman preferred. Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers.

Responsibilities:

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.  Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. 
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Required:

• Graduate of an accredited school of nursing
• 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
• RN: AZ or Compact License
• Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used

Preferred:

• Bachelor's Degree in Nursing (BSN) or related healthcare field 
• At least five (5) years of nursing experience
• Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification