RN Utilization Review

St Mary Medical Center; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

St. Mary Medical Center seeks an Utilization Review Nurse to support the Utilization Management Hub. You will review medical records, authorize services, and prepare cases for physician review in collaboration with UM teams.

Successful candidates bring a clinical background with strong UM/regulatory knowledge and excellent analytical skills to ensure quality patient care, regulatory compliance, and responsible resource use in a fast-paced environment.

Qualifications

• Minimum two years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• California RN license.
• AHA BLS.
• Ability to pass annual Inter-rater reliability test for Utilization Review products used.
• Proficient in application of clinical guidelines (MCG/InterQual) preferred.
• Knowledge of managed care and payer environment preferred.
• Must have critical thinking and problem-solving skills.
• Collaborate effectively with multiple stakeholders.
• Professional communication skills.
• Understand how utilization management and case management programs integrate.
• Ability to work as a team player and assist other members of the team where needed.
• Thrive in a fast paced, self-directed environment.
• Knowledge of CMS standards and requirements.
• Proficient in prioritizing work and delegating where indicated.
• Highly organized with excellent time management skills.

Responsibilities

• Reviews admission and continued stay reviews per Care Coordination Utilization Review guidelines.
• Reviews the records for appropriate status and addresses deficiencies with providers.
• Communicates outcomes with physicians, payers, Care Coordinators and other stakeholders.
• Collaborates with RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated.

Skills

Critical thinking

Problem-solving

Professional communication

Collaboration

Time management

Organizational skills

Education

RN license (California)

Master's degree in Case Management or Nursing

CCM/ACM-RN/UM Certification

BSN preferred

Tools

MCG guidelines

InterQual guidelines

Job description

Where You'll Work

Founded in 1923, Dignity Health - St. Mary Medical Center is a 389-bed, acute care, nonprofit hospital located in Long Beach, California. Serving over 80,000 patients annually, the hospital offers a full complement of services including a Level II Trauma Center, Level III NICU, heart care, and orthopedics. Additionally, St. Mary Medical Center has been recognized as an LGBTQ+ Healthcare Equality High Performer by the Human Rights Campaign Foundation. It is a Joint Commission-certified Thrombectomy-Capable Stroke Center and received a Healthgrades 5-Star Award for Heart Failure in 2026.

One Community. One Mission. One California

Job Summary and Responsibilities

As our Utilization Review Nurse at the Utilization Management Hub, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision-making, regulatory compliance, and responsible resource utilization.

Every day you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria.

To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow.

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.
• Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Job Requirements

• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• California RN license.
• AHA BLS
• Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used.
• Proficient in application of clinical guidelines (MCG/InterQual) preferred
• Knowledge of managed care and payer environment preferred.
• Must have critical thinking and problem-solving skills.
• Collaborate effectively with multiple stakeholders
• Professional communication skills.
• Understand how utilization management and case management programs integrate.
• Ability to work as a team player and assist other members of the team where needed.
• Thrive in a fast paced, self-directed environment.
• Knowledge of CMS standards and requirements.
• Proficient in prioritizing work and delegating where indicated.
• Highly organized with excellent time management skills.

Preferred

• Graduate of an accredited school of nursing (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 (ACM-RN), or UM Certification