RN Utilization Management & Denial Specialist

Carle; Champaign (IL); On-site; USD 50,000 - 80,000; Full time

Job summary

Carle Foundation Hospital seeks a UM staff RN to oversee admission review, documentation, and utilization management for hospitalized patients. You will coordinate care to ensure medical necessity and reimbursement, while collaborating with physicians and payers.

The role requires IL RN licensure, an associate degree in nursing, and experience with care coordination and EPIC Case Management in a hospital setting.

Qualifications

• Active IL RN license.
• Associate's Degree in Nursing or College Diploma in Nursing.
• Experience in utilization management or hospital case coordination preferred.

Responsibilities

• UM staff RN ensures cost-effective, appropriate use of health care services.
• Initial assessment of new patients for correct status (admission/observation/outpatient).
• Performs concurrent reviews to identify practice trends and resource utilization.
• Communicates with physicians on status changes and documentation; data entry in case management systems.
• Track avoidable days and educate physicians on resource utilization.

Skills

Interpersonal communication

Data management

Medical terminology

Education

Associate's Degree in Nursing

Licensed RN (IL)

Tools

EPIC Case Management

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Carle Foundation Hospital seeks a UM staff RN to oversee admission review, documentation, and utilization management for hospitalized patients. You will coordinate care to ensure medical necessity and reimbursement, while collaborating with physicians and payers.

The role requires IL RN licensure, an associate degree in nursing, and experience with care coordination and EPIC Case Management in a hospital setting.