Remote RN Utilization Review Specialist (PT)

Trinity Health; Mishawaka (IN); Remote; USD 55,000 - 69,000; Part time

Benefits offered by this job

Tuition reimbursement

Comprehensive benefits beginning day 1

Retirement savings plan with employer

Generous paid time off and holidays

No mandatory overtime

Employee referral incentive

CEUs and access to state-of-the-art设备

Team-focused environment

Job summary

Saint Joseph Health System is seeking an RN Utilization Review specialist for a part-time, remote PRN role that requires on-site training in Mishawaka, Indiana. The position emphasizes reviewing medical necessity, insurance requirements, and discharge planning in collaboration with physicians and care teams.

Ideal candidates hold an RN license, with a BSN preferred, and have at least 2 years of acute care experience.

Qualifications

• Graduate of an accredited Registered Nurse (RN) program; Bachelor’s Degree in Nursing preferred.
• Active RN license (state-specific requirement applies)
• Minimum of 2 years of acute care nursing experience
• Prior utilization review, case management, or payer review experience preferred
• Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
• Excellent communication skills with the ability to collaborate effectively across teams

Responsibilities

• Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
• Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
• Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
• Review admissions and ongoing patient cases; recommend or upscale cases that do not meet criteria to leadership or the Utilization Review Committee
• Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
• Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
• Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
• Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
• Maintain accurate records, compile reports, and support utilization review program operations
• Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
• Support compliance with all regulatory, accreditation, and organizational standards
• Participate in committee meetings and assist in development of utilization review plans and processes

Skills

Utilization review

Payer review

Medicare/Medicaid knowledge

Regulatory guidelines

Collaboration with physicians

Analytical thinking

Microsoft Office

Communication

Education

RN program graduate

BSN preferred

Tools

Electronic Health Records

Microsoft Office

Job description

Saint Joseph Health System is seeking an RN Utilization Review specialist for a part-time, remote PRN role that requires on-site training in Mishawaka, Indiana. The position emphasizes reviewing medical necessity, insurance requirements, and discharge planning in collaboration with physicians and care teams.

Ideal candidates hold an RN license, with a BSN preferred, and have at least 2 years of acute care experience.