Remote Utilization Review RN – Care Optimization & Coordination

CoxHealth; Missouri; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Vision insurance

Dental insurance

Employer retirement match

Job summary

CoxHealth is seeking a Utilization Review Nurse (RN) to collaborate with physicians and a multidisciplinary team to ensure high-quality, cost-effective patient care. The role focuses on concurrent medical record reviews to assess medical necessity and level of care, determining inpatient vs observation needs, and communicating findings to payers.

Required: Missouri RN license with hospital experience; preferred: Bachelor's in Nursing and CCM certification.

Qualifications

• Graduate of an accredited nursing program.
• Preferred: Bachelor’s degree in Nursing with knowledge of InterQual Criteria and Milliman guidelines.
• Minimum of 3 years hospital experience.
• Current RN license active in Missouri.
• Preferred: Certified Case Manager.

Responsibilities

• Collaborate with physicians and multidisciplinary team to facilitate progression of care.
• Monitor patient progress to ensure plans are patient-focused, high-quality, and cost-effective.
• Conduct concurrent medical record reviews for medical necessity and level of care.
• Determine appropriateness of inpatient vs observation services and communicate with payers.
• Educate physicians and staff on resource utilization and coverage determinations.

Skills

Interpersonal skills

Communication skills

Team collaboration

Medical terminology

Education

Graduate of accredited School of Nursing

Bachelor's degree in Nursing (preferred)

Tools

InterQual Criteria

Milliman Care Guidelines

Job description

CoxHealth is seeking a Utilization Review Nurse (RN) to collaborate with physicians and a multidisciplinary team to ensure high-quality, cost-effective patient care. The role focuses on concurrent medical record reviews to assess medical necessity and level of care, determining inpatient vs observation needs, and communicating findings to payers.

Required: Missouri RN license with hospital experience; preferred: Bachelor's in Nursing and CCM certification.