RN Utilization Review Case Manager

Gateway Regional Medical Center, Inc.; Granite City (IL); On-site; USD 44,083 - 66,124; Full time

Benefits offered by this job

Competitive salary and performance‑based incentives

Comprehensive health, dental, and vision insurance

Retirement savings plan with employer matching

Vacation time and holiday pay

Supportive and inclusive work environment

Job summary

Gateway Regional Medical Center, Inc. is seeking a full-time Utilization Review Specialist RN responsible for conducting admission and concurrent reviews to avoid payment denials, while managing appeals. This role requires collaboration with interdisciplinary teams to enhance patient outcomes and promote efficient resource utilization.

Candidates must have five years of nursing experience in an acute care setting, current nursing license, and knowledge of relevant criteria is preferred. The position offers a competitive salary, health benefits, and a supportive work environment.

Qualifications

• Minimum of five years of clinical nursing experience in an acute care setting required.
• Current Illinois Nursing License is mandatory.
• Experience in case management, utilization review, or appeals management preferred.

Responsibilities

• Conduct admission and concurrent reviews to prevent denials.
• Coordinate and manage appeals for accounts worthy of reconsideration.
• Promote compliance with payer, regulatory, and accreditation standards.

Skills

Clinical nursing experience

Knowledge of InterQual and/or Milliman criteria

Education

Graduate of an Accredited School of Professional Nursing

Tools

Basic Life Support (AHA or American Red Cross BLS)

Job description

We are Gateway Regional Medical Center

Our mission is to provide compassionate, high-quality healthcare services to our community, promoting wellness and healing through innovative treatments, advanced technology, and a dedicated team of professionals. We are committed to fostering a culture of respect, integrity, and excellence, ensuring that every patient receives personalized care in a safe and nurturing environment. Together, we strive to enhance the health and well‑being of those we serve and to be a trusted partner in their journey to better health.

Position Overview

The Utilization Review Specialist RN assumes responsibility and accountability for admission and concurrent reviews to ensure the prevention of denials from all payers, as well as coordination and management of appeals for accounts deemed appropriate for appeal. This role supports compliance with payer, regulatory, and accreditation standards while promoting efficient utilization of healthcare resources and quality patient outcomes. The Specialist works collaboratively with interdisciplinary teams to identify denial trends, improve workflows, and ensure timely resolution of utilization review and appeals processes.

Specifics

• Position: Utilization Review Specialist RN
• Department: Case management
• Location: Gateway Regional Medical Center, 2100 Madison Ave., Granite City, IL 62040
• Position Status: Full‑time

Education Qualifications

• Graduate of an Accredited School of Professional Nursing

Certification Qualifications

• Current Illinois Nursing License
• Current Basic Life Support (AHA or American Red Cross BLS) certification
• Preferred: Knowledge of InterQual and/or Milliman criteria

Experience Qualifications

• Minimum of five years of clinical nursing experience in an acute care setting required.
• Experience in case management, discharge planning, utilization review, or appeals management preferred.

Company Benefits

• Competitive salary and performance‑based incentives
• Comprehensive health, dental, and vision insurance plans
• Retirement savings plan with employer matching
• Vacation time and holiday pay
• Supportive and inclusive work environment

Pay Range

• The pay range for this position is $32.00 - 48.00 per hour.

Disclaimer: Pay is determined based on various factors, including education level, years of experience, relevant certifications, and specific skills related to the position. The final compensation package will be discussed with Human Resources to ensure fairness and alignment with the candidate's qualifications.