Utilization Review Registered Nurse : On Site Position

Pioneers Medical Center; Northern (KY); Hybrid; USD 45,000 - 73,000; Part time

Job summary

Pioneers Medical Center is seeking a Part-Time Utilization Review Nurse (RN) to assess medical necessity and appropriateness of admissions and care levels in a Colorado hospital setting. This role includes concurrent and retrospective reviews, collaboration with physicians and Case Management, and documentation in the EHR.

Strong knowledge of payer guidelines is essential. The position supports discharge planning and appeals processes, with an emphasis on reducing readmissions and denials, and

Qualifications

• Active, unencumbered RN license in Colorado or a Compact-state license that includes Colorado.
• Two to three years of recent clinical experience in an acute care setting.
• One year of experience in Utilization Review or Case Management preferred.
• Strong knowledge of Medicare, Medicaid, and commercial payer regulations.

Responsibilities

• Conduct utilization reviews to determine medical necessity and appropriate level of care.
• Perform concurrent and retrospective utilization reviews using InterQual /Milliman criteria.
• Communicate with physicians and staff regarding medical necessity and documentation requirements.
• Identify barriers to discharge and collaborate with Case Management for timely progression.
• Document all activities in the EHR and assist with appeals for denied services.
• Stay current with payer regulations and medical necessity criteria.
• Coordinate discharge planning with orthopedic patients and UR committee involvement.

Education

Registered Nurse license (Colorado or Compact-state)

Job description

Job Category: Nursing RN LPN CNA PCT MA CMA

Requisition Number: UTILI001161

• Posted : February 26, 2026
• Part-Time

Locations

Showing 1 location

Meeker, CO 81641, USA

Description

Reports To : Director of Nursing; Acute and Emergency Department

FLSA Classification: Part-Time, Non-Exempt, Hourly $33.50 - $49-53

Essential Functions:

• The Part-Time Utilization Review Nurse is a Registered Nurse (RN) responsible for conducting utilization reviews to determine the medical necessity and appropriateness of patient admissions, continued hospital stays, and the level of care provided. This role ensures compliance with regulatory requirements and payer guidelines, proactively identifies potential barriers to discharge, and works to prevent claim denials, thereby supporting efficient patient throughput and optimal resource utilization within the hospital.
• Perform concurrent and retrospective utilization reviews for all patient admissions and continued stays, applying established medical necessity criteria (e.g. InterQual, Milliman Care Guidelines), and payer specific guidelines.
• Communicate effectively with attending physicians, residents, and other healthcare providers regarding medical necessity, documentation requirements, and alternative levels of care.
• Identify and address potential barriers to discharge, collaborating with the Case Management team to facilitate timely patient progression.
• Document all review activities, including approvals, denials, and appeals processes, accurately and thoroughly in the electronic health record (EHR) system.
• Assist in the preparation and submission of appeals for denied services, providing clinical rationale and supporting documentation.
• Stay current with Medicare, Medicaid, and commercial payer regulations, policies, and medical necessity criteria.
• Collaborate with the Case Management team to ensure seamless coordination between utilization review and discharge planning activities.
• Participate in interdisciplinary team meetings to discuss patient status, care progression, and discharge readiness.
• Provide education to physicians and other staff on documentation requirements for medical necessity.
• Monitor readmissions and avoidable days in Meditech for quality improvement initiatives.
• Coordinate in advance discharge planning for orthopedic surgical patients, ensuring timely referrals, equipment orders, and post-discharge services.
• Actively participate in the Utilization Review (UR) Committee.
• Perform other duties as assigned to support utilization management, case management, and hospital operations.
• Other duties as assigned.

Education and Experience:

• Previous experience in managing staff and schedules required.
• Active, unencumbered Registered Nurse (RN) license in Colorado or Compact-state license that includes Colorado.
• Two (2) to three (3) years’ of recent clinical experience in an acute care setting required.
• One (1) year of experience in Utilization Review or Case Management preferred.
• Strong knowledge of Medicare, Medicaid, and commercial payer regulations, as well as medical necessity criteria (e.g., InterQual, Milliman Care Guidelines).

Equal Opportunity Employer
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