[Hiring] Utilization Review RN @CommonSpirit Health

Role Description

As our Utilization Review RN, you will meticulously review medical records to confirm appropriate admission status and continued hospitalization, utilizing established criteria and critical thinking. You'll work hand-in-hand with Concurrent Denial RNs to identify the root causes of denials and implement proactive prevention strategies. This role is essential for collaborating with Patient Access to verify payer sources, documenting interactions, and obtaining inpatient authorization from insurance providers, ensuring seamless patient journeys and financial integrity.

• Conduct admission, concurrent, and post-discharge reviews, ensuring compliance with utilization review principles, hospital policies, and external regulatory agencies like PRO and Joint Commission.
• Identify deficiencies with providers regarding accurate patient status orders.
• Facilitate timely communication with all stakeholders—physicians, payers, and Care Coordinators—regarding review outcomes.
• Support the second-level physician reviewer, coordinating peer-to-peer discussions.
• Document a working DRG on each assigned patient at initial review.

To be successful in this role, you will possess:

• Critical thinking and problem-solving skills.
• Exceptional professional communication abilities.
• A strong collaborative spirit.
• The ability to thrive in a fast-paced, self-directed environment.
• Meticulous attention to detail.
• Knowledge of a managed care and payer environment.
• Proficiency in applying clinical guidelines.

Qualifications

• Associate's Degree in Nursing.
• Minimum two (2) years of acute hospital clinical experience or a Master's degree in Case Management or Nursing field in lieu of one (1) year experience.
• RN License; Current state nursing licenses or valid RN license from a participating state in the National Licensure Compact.
• Ability to pass annual Interrater reliability test for Utilization Review product(s) used.
• Understanding of how utilization management and case management programs integrate.
• Knowledge of CMS standards and requirements.

Requirements

• 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 (ACMRN), or UM Certification.
• Proficient in application of clinical guidelines (MCG/InterQual).
• Knowledge of managed care and payer environment.

Company Description

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.