RN: Utilization Review Pro (PRN)

ummc; Missouri; On-site; USD 40,000 - 65,000; Part time

Job summary

Utilization Review is seeking a Registered Nurse to perform utilization management for a designated patient load, including prospective, concurrent, retrospective and denial reviews, in a part-time capacity at Main Campus Jackson.

The role requires 1 year of inpatient nursing experience and a valid RN license, with strong knowledge of medical necessity criteria and effective communication with the care team and payers.

Qualifications

• One year of inpatient nursing experience.
• Valid RN license.
• Knowledge of utilization review and case management processes.

Responsibilities

• Perform prospective, concurrent, retrospective, and denials reviews for cases including medical necessity and level of care.
• Collect and report indicators (case mix, LOS, cost/case, denials, appeals).
• Use data to drive performance-improvement in case management (clinical, fiscal, patient satisfaction).
• Analyze variances from plan of care; collaborate with physicians to improve outcomes.
• Apply clinical criteria to monitor admissions; refer cases as needed.
• Communicate with payers to facilitate reimbursement and resolve issues.
• Collaborate with care teams to ensure timely, appropriate management.
• Ensure safe, high-quality care within policies and budget constraints.

Skills

Utilization review knowledge

discharge planning

case management

medical terminology (ICD-10, CPT, DSM)

communication skills

data gathering & reporting

independent judgment

CQI focus

computer/software proficiency

Education

RN license

Job description

Utilization Review is seeking a Registered Nurse to perform utilization management for a designated patient load, including prospective, concurrent, retrospective and denial reviews, in a part-time capacity at Main Campus Jackson.

The role requires 1 year of inpatient nursing experience and a valid RN license, with strong knowledge of medical necessity criteria and effective communication with the care team and payers.