Utilization Review RN

CommonSpirit Health; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

A community hospital in Arizona is seeking a Utilization Management Nurse to ensure healthcare efficiency and quality through diligent review of medical records and adept communication. You'll engage with multiple stakeholders to uphold clinical decision-making and regulatory compliance. The ideal candidate will have strong nursing experience and an understanding of utilization review principles. Join us in providing comprehensive patient care in a supportive environment.

Qualifications

• Graduate of an accredited school of nursing.
• Minimum two years of acute hospital clinical experience or a Master's degree in Case Management in lieu of 1-year experience.
• RN: AZ or Compact License.

Responsibilities

• Conduct admission and continued stay reviews per guidelines.
• Ensure compliance with utilization review principles and hospital policies.
• Communicate and follow up with physicians, payers, and other stakeholders.

Skills

Knowledge of federal, state and managed care rules

Excellent written and verbal communication skills

Working knowledge with INTERQUAL or Milliman

Education

Graduate of an accredited school of nursing

Bachelor's Degree in Nursing (BSN)

Job description

Where You’ll Work

Hello humankindness

Dignity Health’s Mercy Gilbert Medical Center is nationally known for our holistic approach to medicine, and here, you are a part of a “golden thread” of compassionate care that connects staff and patients. While walking through the Healing Garden–with it’s intertwined pathways, garden areas and fountains–you’re reminded of our dedication to honoring the whole person. Embracing total well‑being, then seeing patients and their loved ones respond positively, is personally rewarding to you. Dignity Health is one of the largest healthcare systems in the West with over 40 hospitals in Arizona, California and Nevada. Mercy Gilbert is a modern, 212‑bed, acute care, not‑for‑profit community hospital in the Phoenix area’s East Valley. We offer a full breadth of care, from emergency and cardiovascular to pediatric, orthopedic and diagnostic services. Since opening in June 2006, we have been named the “#1 Small‑Sized Acute Care Hospital” by Arizona Business Magazine and the “#1 Healing Hospital in the Nation” by Baptist Healing Trust. We’ve also been named “Business of the Year” by the Gilbert Chamber of Commerce. You’re proud of these awards, but even more, you’re proud of the solace, serenity and reprieve you’re able to provide here.

Living in Phoenix’s relatively new suburb Gilbert, Arizona, you treasure its old‑world charm mixed with modern‑day luxuries. This urban center has all the shopping, restaurants and culture your heart desires, with all the outdoor activities your spirit needs. There are nearby lakes for boating, wakeboarding and water skiing, while Flagstaff and Sunrise offer winter skiing and snowboarding. Arizona has four professional sports teams, and you’re a year‑round fan. You look forward to all the activities, but then again, at the end of a busy day, taking a moment to relax poolside and reflect sounds good, too. The scenery, the climate and the culture present the perfect backdrop for your healing work at Mercy Gilbert.

Now is the perfect time to grow your career with one of Arizona's Most Admired Companies. Look for us on Facebook and follow us on Twitter.

For the health of our community ... we are proud to announce that we are a tobacco‑free campus.

Job Summary and Responsibilities

As our Utilization Management Nurse, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision‑making, regulatory compliance, and responsible resource utilization.

Every day, you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost‑effectiveness, aligning decisions with established criteria.

To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow.

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:

• 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.
• 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.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or ex

Job Requirements

Required:

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

Preferred:

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