Utilization Review Nurse

Santa Barbara Cottage Hospital; United States; Remote; USD 65,000 - 95,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Utilization Review Nurse to join their team. This role involves conducting critical reviews to ensure efficient resource use and high-quality patient care. You will collaborate with clinical staff and stakeholders to maintain compliance with healthcare regulations and improve patient satisfaction. The organization values its employees and offers an Education Benefit program to support your professional growth. If you're passionate about making a difference in patient care and enjoy a collaborative work environment, this opportunity is perfect for you.

Benefits

Education Benefit program

Debt relief and student loan assistance

Up to $18,000 for full-time employees

Up to $9,000 for part-time employees

Qualifications

• Minimum two years of acute hospital clinical experience or Master's degree in Case Management.
• RN: AZ or Compact License required.

Responsibilities

• Conducts admission and continued stay reviews for appropriate hospitalization.
• Ensures compliance with utilization review principles and hospital policies.

Skills

Knowledge of federal, state, and managed care rules

Working knowledge with INTERQUAL or Milliman

Excellent written and verbal communication skills

Education

Graduate of an accredited school of nursing

Bachelor's Degree in Nursing (BSN) or related healthcare field

Master's degree in Case Management or Nursing

Tools

Utilization Review product(s)

Job description

Overview

Hello Humankindness, Chandler, Arizona, has a stable suburban population with an economy anchored by many large financial and high-tech companies. Located southeast of Phoenix, Chandler is a skillfully developed community of friendly, diverse neighborhoods with expansive parks, great schools, convenient shopping, and excellent career opportunities.

For more than 50 years, Dignity Health’s Chandler Regional Medical Center has focused on quality patient care and service to the community. As the longest established hospital in the southeast valley, Chandler Regional has provided care for the Chandler community since 1961. The hospital recently added a new five-story tower with 96 patient beds, increasing the acute-care bed count to 338. This expansion increased emergency and trauma services, as well as the surgical unit and intensive care offerings.

The word “dignity” perfectly defines what our organization stands for: showing respect for all people by providing excellent care. At Chandler Regional, our employees are the heart and soul of our organization. They are the reason we are able to live out our healing ministry within the communities we serve. Our doctors, nurses, and allied health professionals are a regular self-contained support system for each other. This unique working culture is one of the reasons why a career with us is so rewarding. Now is the perfect time to come grow your career with one of Arizona's Most Admired Companies.

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Responsibilities

Under the general direction of the Director of Care Management, performs criteria-based concurrent and retrospective utilization review to support and encourage the efficient and effective use of resources; promote quality patient care; assist with patient care management; comply with applicable standards and regulations and provide information and education to clinical care providers in order to achieve optimal clinical, financial, operational, and patient satisfaction outcomes.

Skills needed:

Knowledge of federal, state, and managed care rules and regulations including CMS and AHCCCS. Working knowledge with INTERQUAL or Milliman preferred. Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers, and post-acute care providers.

Responsibilities:

1. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent, and post-discharge for appropriate status determination.
2. Ensures compliance with principles of utilization review, hospital policies, and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer-defined criteria for eligibility.
3. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
4. Ensures timely communication and follow-up with physicians, payers, Care Coordinators, and other stakeholders regarding review outcomes.
5. Collaborates with facility RN Care Coordinators to ensure progression of care.
6. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Dignity Health now offers an Education Benefit program for benefit-eligible employees after 180 days. This program provides debt relief and student loan assistance to help you achieve your goals. Full-time employees can receive up to $18,000 over five years, while part-time employees can receive up to $9,000.

Qualifications

Minimum:

1. Graduate of an accredited school of nursing
2. Minimum two (2) years of acute hospital clinical experience or a Master's degree in Case Management or Nursing field in lieu of 1 year experience
3. RN: AZ or Compact License
4. Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used

Preferred:

1. Bachelor's Degree in Nursing (BSN) or related healthcare field
2. At least five (5) years of nursing experience
3. Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification