RN Utilization Management: Care Optimization & Compliance

St. Charles Health System; Bend (OR); On-site; USD 100,464 - 150,696; Full time

Job summary

St. Charles Health System is seeking an RN for Utilization Management to perform pre-admission status reviews, ensure medical necessity, and coordinate with CM, physicians, and payors. The role emphasizes data tracking, denial avoidance, and continuous improvement within regulatory requirements.

The position reports to the Manager of Utilization Management and requires strong collaboration across departments to optimize patient status, outcomes, and payer communications.

Qualifications

• Graduate of an accredited nursing school.
• Current Oregon RN license.
• Three years acute care clinical nursing experience.
• Two years Utilization Management experience.
• Two years’ experience working with electronic health records (EHR).

Responsibilities

• Performs pre-admission status recommendation review for multiple care settings and provides status guidance to providers.
• Ensures appropriate patient status upon admission and manages status conversions.
• Ensures completion of admission medical necessity reviews within 24 hours of admission.
• Performs concurrent inpatient medical necessity reviews at least every 3 days and Observation reviews at least every 12 hours.
• Completes discharge reviews and escalates concerns to ensure medical necessity and appropriate authorization.
• Collaborates with Care Management, physicians, payors and other stakeholders to address medical necessity and LOC changes.

Skills

Acute care nursing

UM experience

EHR experience

Education

Graduate of an accredited school of nursing

Job description

St. Charles Health System is seeking an RN for Utilization Management to perform pre-admission status reviews, ensure medical necessity, and coordinate with CM, physicians, and payors. The role emphasizes data tracking, denial avoidance, and continuous improvement within regulatory requirements.

The position reports to the Manager of Utilization Management and requires strong collaboration across departments to optimize patient status, outcomes, and payer communications.