RN Utilization Review Specialist – Nights (Inpatient Care)

Onvida Health; Yuma (AZ); On-site; USD 61,000 - 97,000; Full time

Job summary

Onvida Health is seeking an RN Utilization Review Specialist to perform prospective and concurrent medical record reviews to determine medical necessity and appropriate level of care in line with CMS regulations and payer requirements.

You will communicate with payers to obtain authorizations, support appeals, and educate clinicians on documentation standards to ensure compliant, efficient care and optimal reimbursement.

Qualifications

• Associates Degree
• 3 years related experience
• AZ RN License
• BLS (AHA)

Responsibilities

• Performs admission and continued stay reviews using CMS criteria to determine inpatient or observation status.
• Monitors length of stay and flags cases at risk of medical necessity denial.
• Documents determinations in UR systems per departmental standards.
• Ensures CMS/Medicare compliance and applies payer notification requirements (HINN, ABN, MOON, IMM, CC44).
• Communicates with payers to obtain authorizations; supports denial prevention and appeals.
• Educates providers on documentation improvements to support medical necessity and reimbursement.

Education

Associate's Degree

Job description

Onvida Health is seeking an RN Utilization Review Specialist to perform prospective and concurrent medical record reviews to determine medical necessity and appropriate level of care in line with CMS regulations and payer requirements.

You will communicate with payers to obtain authorizations, support appeals, and educate clinicians on documentation standards to ensure compliant, efficient care and optimal reimbursement.