[Hiring] Utilization Review RN @CommonSpirit Health

Role Description

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.

• Meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams.
• Monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria.
• Possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills.
• Manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy.

Qualifications

• 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.
• Ability to interact with patients/family, clinical staff, insurance providers, and post-acute care providers.

Requirements

• Graduate of an accredited school of nursing.
• Minimum two (2) years of acute hospital clinical experience or a Master's 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.