Utilization Review RN - Care Coordination & Compliance

UofL Health, Inc.; Louisville, Northern (KY, KY); Hybrid; USD 70,000 - 100,000; Full time

Job summary

UofL Health, Inc. in Louisville is seeking an Utilization Review RN to support the UM process.

The role focuses on determining medical necessity for admission and continued stay, aligning care with payer guidelines, and coordinating with physicians and case managers for approvals and denials. The position requires active RN licensure in Kentucky, 2+ years of RN experience, and familiarity with Case Management processes.

Qualifications

• ADN or Associate’s degree in nursing (Required).
• RN with a bachelor’s degree in business, Health Care Administration or equivalent may enroll in BSN within 1 year and complete within 3 years.
• Two years’ RN experience required; additional case management/UM experience preferred.
• Case Management Certification preferred.
• Active Kentucky RN license.

Responsibilities

• Promotes optimal management of clinical resources by conducting timely admission and concurrent utilization reviews.
• Certifies medical necessity for admission, continued stay and discharge reviews using current criteria.
• Communicates with physicians and care team to obtain approvals and document authorization details.
• Educates physicians, patients, and staff on payor requirements and documentation.
• Works with third-party payers to secure authorizations and manage length of stay.

Skills

Utilization review

Nursing

Case management

Communication

Interdisciplinary teamwork

Regulatory knowledge

Education

Associate degree in nursing

BSN preferred

Tools

Case Management Software

EMR systems

Job description

UofL Health, Inc. in Louisville is seeking an Utilization Review RN to support the UM process.

The role focuses on determining medical necessity for admission and continued stay, aligning care with payer guidelines, and coordinating with physicians and case managers for approvals and denials. The position requires active RN licensure in Kentucky, 2+ years of RN experience, and familiarity with Case Management processes.