Utilization Review RN

CHI Health; Omaha (NE); On-site; USD 85,000 - 105,000; Full time

Job summary

CommonSpirit Health is seeking an Utilization Review Registered Nurse in Omaha, NE to optimize hospital care by validating medical necessity and patient status through established guidelines such as MCG or InterQual. The role requires collaboration with physicians, care coordinators, and payers to ensure smooth care transitions.

The UR RN will conduct admission and concurrent reviews, support denial prevention, and participate in peer-to-peer reviews while maintaining compliance with CMS and

Qualifications

• RN license in NE or IA required.
• 2+ years of acute hospital clinical experience.
• Experience with utilization management programs and clinical criteria application.

Responsibilities

• Perform admission and concurrent stay reviews to validate clinical necessity.
• Engage in denial prevention strategies.
• Coordinate peer-to-peer reviews between providers and payers.
• Communicate critical status updates to stakeholders.
• Ensure regulatory compliance and high-quality patient care.

Skills

Utilization management

CMS standards

Clinical documentation

Time management

Collaboration

Education

BSN

MS in Case Management or related field

Tools

MCG criteria

InterQual criteria

CMS guidelines

Job description

Job Summary and Responsibilities

As our Utilization Review RN, you will play a pivotal role in optimizing healthcare delivery by ensuring medical necessity and appropriate patient status throughout the hospitalization journey. You will serve as a clinical expert, collaborating with attending physicians, consultants, and care coordination teams to apply evidence-based guidelines—such as MCG or InterQual—to facilitate seamless patient care transitions. Your expertise in managed care environments and CMS standards will be essential in navigating payer requirements, preventing claim denials, and upholding the high-quality standards of our health system.

Every day you will perform comprehensive admission and concurrent stay reviews to validate the clinical necessity of care, ensuring every patient interaction is documented with precision. You will engage in proactive denial prevention strategies, coordinate peer-to-peer reviews between providers and insurance payers, and communicate critical status updates to stakeholders. By balancing clinical data analysis with professional communication, you will ensure our facility remains compliant with regulatory agencies and Joint Commission standards while supporting the overall progression of care for our diverse patient population.

To be successful in this role, you will hold an active Registered Nurse (RN) license in NE or IA and possess at least two years of acute hospital clinical experience. We are seeking a detail-oriented professional with a strong grasp of utilization management programs, excellent time management skills, and the ability to thrive in a fast-paced, self-directed environment. Proficiency in clinical criteria application, a collaborative mindset, and a commitment to our organizational mission and core values are required to succeed as a key member of our utilization management team.

Job Requirements

Required

• Graduate of an accredited school of nursing and 1-3 years Minimum two (2) years of acute hospital clinical experience , upon hire or
• Masters Other In Case Management or Nursing field in lieu of 1 year experience., upon hire and
• Registered Nurse: NE, upon hire or
• Registered Nurse: IA, upon hire and

Preferred

• Bachelors Of Science BSN in Nursing or related healthcare field and 4-6 years Five years of nursing experience, upon hire
• Certified Case Manager, upon hire and
• Accredited Case Manager, upon hire

Where You'll Work

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S., from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.