Utilization Management RN: Denials & Care Optimization

Carle Health; Champaign (IL); On-site; USD 75,000 - 121,000; Full time

Job summary

Carle Health is seeking a skilled staff RN to oversee and coordinate care for hospitalized patients within the IP Care Coordination Department. You will ensure medical necessity, optimize LOS, and support efficient admissions and ongoing reviews.

Responsibilities include concurrent chart reviews, communication with physicians and payers, and escalation when medical necessity criteria or appropriate level of care are not met. Strong data skills and Epic experience are essential.

Qualifications

• Licensed RN in Illinois per IDFPR requirements.
• Associate's Degree in Nursing or college nursing diploma.
• RN licensure and nursing education required.

Responsibilities

• Function in IP Care Coordination to ensure cost-effective and appropriate use of services.
• Perform initial and concurrent reviews to assess admission status and resource utilization.
• Communicate with physicians on status changes and documentation; refer cases for escalation when needed.
• Track avoidable days and participate in quality reviews with UM Leadership.
• Assist appeals staff in concurrent and retrospective reviews.

Skills

Attention to detail

Interpersonal communication

Data management

EPIC Case Management

Education

Assoc. degree in Nursing

Nursing diploma

Tools

EPIC Case Management software

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Carle Health is seeking a skilled staff RN to oversee and coordinate care for hospitalized patients within the IP Care Coordination Department. You will ensure medical necessity, optimize LOS, and support efficient admissions and ongoing reviews.

Responsibilities include concurrent chart reviews, communication with physicians and payers, and escalation when medical necessity criteria or appropriate level of care are not met. Strong data skills and Epic experience are essential.