Utilization Management RN - Quality & Cost Optimization

Capital Health System, Inc.; Hopewell (VA); On-site; USD 82,000 - 107,000; Full time

Benefits offered by this job

Medical plan

Dental plan

Vision plan

Flexible Spending Account

Job summary

Capital Health seeks an experienced Utilization Management RN to perform chart reviews and admission reviews for Medicare/Medicaid and private pay patients, determining appropriate levels of care per CMS guidelines. You will collaborate with care teams, physicians and payers, participate in daily huddles, and contribute to performance improvement while promoting cost‑effective, high‑quality patient care.

Requires nursing degree and RN license; five years of nursing and three years in

Qualifications

• Associate's degree in nursing; graduate of accredited nursing program.
• CPHQ, CCM or CPUR credentials preferred.
• Five years' clinical nursing experience and three years in quality management, utilization review or discharge planning.

Responsibilities

• Review charts to assess quality, timeliness and appropriateness of patient care.
• Conduct admission reviews for Medicare, Medicaid, and private pay patients using guidelines.
• Identify appropriate level of care and coordinate with UR physician advisor.
• Collaborate with care teams and payers to resolve progression of care barriers.
• Participate in daily huddles and performance improvement activities.

Skills

Problem solving

Team collaboration

Regulatory compliance

Clinical nursing experience

Education

Associate's degree in nursing

Graduate of accredited nursing school

CPHQ, CCM or CPUR preferred

Tools

Microsoft Office

UR software

EMR

MCG guidelines

Job description

Capital Health seeks an experienced Utilization Management RN to perform chart reviews and admission reviews for Medicare/Medicaid and private pay patients, determining appropriate levels of care per CMS guidelines. You will collaborate with care teams, physicians and payers, participate in daily huddles, and contribute to performance improvement while promoting cost‑effective, high‑quality patient care.

Requires nursing degree and RN license; five years of nursing and three years in