Utilization Nurse

Community Health Systems; New Port (MD); On-site; USD 52,000 - 76,000; Full time

Job summary

Community Health Systems seeks an Utilization Review Nurse - LPN to coordinate the facility's utilization management activities, including admission reviews, status validations, and documentation support. The role uses third-party criteria to assess medical necessity and supports denial/appeal workflows, aiming to reduce readmissions and improve quality metrics.

Responsibilities include reviewing records, validating status, querying providers, and collaborating with care teams.

Qualifications

• 2-4 years of experience in a hospital or nursing home setting.

Responsibilities

• Review medical records to determine medical necessity for admission using third-party criteria (e.g., MCG, InterQual).
• Validate admission status and identify discrepancies in patient placement.
• Initiate provider queries to clarify documentation and support appropriate utilization.
• Participate in interdisciplinary team meetings to discuss patient care plans and discharge readiness.
• Support process improvement initiatives related to utilization management and readmission reduction.
• Escalate complex or unresolved cases to leadership or physician advisors.
• Maintain compliance with internal policies, payer requirements, and regulatory guidelines.
• Protect patient privacy and PHI security.
• Perform other duties as assigned.
• Maintain regular attendance.
• Complies with all policies and standards.

Skills

Communication

Empathy & professionalism

Utilization management

EHR knowledge

Problem solving

Time management

Job description

Job Summary

The Utilization Review Nurse - LPN coordinates key components of the facility's utilization management program, including admission reviews, status validations, and documentation support. This role performs third-party criteria assessments to determine medical necessity, assists with denial and appeal activities, and supports efforts to reduce unnecessary readmissions. The Utilization Review Nurse - LPN may also contribute to quality assurance and resource management initiatives.

Essential Functions

• Reviews medical records to determine medical necessity for admission using established third-party criteria (e.g., MCG, InterQual).
• Validates admission status and identifies potential discrepancies in patient placement.
• Initiates provider queries to clarify documentation and support appropriate utilization.
• Participates in interdisciplinary team meetings to discuss patient care plans and discharge readiness.
• Supports the implementation of process improvement initiatives related to utilization management and readmission reduction.
• Escalates complex or unresolved cases to appropriate leadership or physician advisors.
• Maintains compliance with internal policies, payer requirements, and regulatory guidelines.
• Protects patient privacy and ensures security of Protected Health Information (PHI).
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• 2-4 years of experience in a hospital or nursing home setting required

Knowledge, Skills and Abilities

• Strong written and oral communication skills.
• Demonstrates empathy, compassion, and professionalism in patient interactions.
• Proficient in utilization management processes, criteria sets, and managed care standards.
• Knowledge of healthcare informatics and Electronic Health Records (EHR) systems.
• Sound problem-solving and critical thinking skills.
• Excellent organizational and time management skills to manage competing priorities.

Licenses and Certifications

• LPN - Licensed Practical Nurse - State Licensure required or
• LVN - Licensed Vocational Nurse required