RN Utilization Review Nurse - Remote Option

Trinityhealth; United States; On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Tuition reimbursement for all full/pt2

Comprehensive benefits from day one

Employer retirement match

Generous PTO and holidays

No mandatory overtime

Employee referral incentive

Access to CEUs and supportive team

Job summary

Saint Joseph Health System is seeking a qualified RN to conduct clinical reviews of patient records, determine medical necessity, and ensure proper utilization of resources across payor types. This remote role requires onsite training in Mishawaka, IN and collaboration with physicians, nurses, and care teams.

The successful candidate will have an active RN license, 2+ years of acute care experience, and knowledge of Medicare/Medicaid guidelines, with strong communication and organizational

Qualifications

• Graduate of an accredited Registered Nurse (RN) program; Bachelor's Degree in Nursing preferred
• Active RN license (state-specific requirement applies)
• Minimum of 2 years of acute care nursing experience
• Prior utilization review, case management, or payer review experience preferred
• Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
• Proficiency in computer systems and Microsoft Office applications
• Ability to manage multiple priorities in a fast-paced healthcare environment
• Excellent communication skills with the ability to collaborate effectively across teams

Responsibilities

• Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
• Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
• Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
• Review admissions and ongoing patient cases; recommend or elevate cases that do not meet criteria to leadership or the Utilization Review Committee
• Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
• Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
• Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
• Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
• Maintain accurate records, compile reports, and support utilization review program operations
• Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
• Support compliance with all regulatory, accreditation, and organizational standards
• Participate in committee meetings and assist in development of utilization review plans and processes

Skills

Communication

Analytical thinking

Microsoft Office

Education

RN license

Bachelor’s in Nursing

Tools

Microsoft Office

Job description

Saint Joseph Health System is seeking a qualified RN to conduct clinical reviews of patient records, determine medical necessity, and ensure proper utilization of resources across payor types. This remote role requires onsite training in Mishawaka, IN and collaboration with physicians, nurses, and care teams.

The successful candidate will have an active RN license, 2+ years of acute care experience, and knowledge of Medicare/Medicaid guidelines, with strong communication and organizational