Utilization Nurse

Community Health Systems; Newport (TN); On-site; USD 42,000 - 64,000; Full time

Job summary

Community Health Systems in Newport, TN is seeking an Utilization Review Nurse - LPN to coordinate admission reviews, status validations, and documentation support within the facility's utilization management program. This role will apply third-party criteria to determine medical necessity and support patient placement decisions.

The position also involves supporting denial and appeal activities, contributing to readmission reduction, quality assurance, and regulatory compliance while protecting

Qualifications

• 2-4 years of hospital or nursing home experience.
• LPN or LVN licensure required.
• Proficient in EHR systems and clinical documentation.

Responsibilities

• Reviews records to determine medical necessity using third-party criteria.
• Validates admission status and identifies discrepancies in patient placement.
• Initiates provider queries to clarify documentation and support utilization.
• Participates in interdisciplinary team meetings to discuss care plans.
• Supports denial and appeal activities and readmission reduction efforts.
• Maintains compliance with policies, payer requirements, and PHI protection.

Education

LPN/LVN licensure

LVN licensure

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