[Hiring] RN - Utilization Reviewer @University of Mississippi Medical Center

Role Description

Accountable to perform utilization management services for designated patient case load, including:

• Prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria.
• Reports quality of care issues identified during the utilization management process to the appropriate manager.
• Perform job duties in accordance with the medical center's purpose.

Qualifications

• Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management.
• InterQual experience preferred.

Requirements

• Valid RN license.
• CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred.
• Knowledge of the aspects of utilization review.
• Excellent interpersonal verbal and written communication and negotiation skills.
• Skills in the use of personal computers and related software applications.
• Ability to gather data, compile information, and prepare reports.
• Ability to identify process improvements.
• Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes.
• Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families.
• Demonstrate commitment to the organization’s mission and the behavioral expectations in all interactions and in performing all job duties.
• Ability to use medical necessity guidelines with minimal supervision.
• Equipped to work remotely to include hardware with high speed internet via cable and Windows 10.

Responsibilities

• Performs all aspects of prospective, concurrent, retrospective, and denials review for individual cases.
• Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
• Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients.
• Collects, analyzes, and addresses variances from the plan of care path with physician and/or other members of the healthcare team.
• Uses concurrent variance data to drive practice changes and positively impact outcomes.
• Documents key clinical path variances and outcomes which relate to areas of direct responsibility.
• Applies approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays.
• Identifies at-risk populations using approved screening tool and follows established reporting procedures.
• Communicates with third party payers to facilitate covered day reimbursement certification for assigned patients.
• Works collaboratively and maintains active communication with physicians, nursing, and other members of the interdisciplinary care team.
• Addresses/resolves system problems impeding diagnostic or treatment progress.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education.
• Actively participates in clinical performance improvement activities.

Environmental and Physical Demands

• Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold.
• Occasional working hours beyond regularly scheduled hours.
• Occasional activities subject to significant volume changes of a seasonal/clinical nature.
• Occasional lifting/carrying up to 25 pounds.
• Frequent sitting, occasional standing, and frequent walking.

Time Type

Part time

FLSA Designation/Job Exempt

Yes

Pay Class

Salary

FTE %

100

Work Shift

Benefits Eligibility

Job Posting Date

06/8/2026