Utilization Review RN: Drive Care Quality & Cost Efficiency

Tuba City Regional Health Care Corporation; Tuba City (AZ); On-site; USD 90,000 - 110,000; Full time

Job summary

Tuba City Regional Health Care Corporation seeks an experienced Utilization Review Nurse to verify medical necessity, monitor patient status, and coordinate discharge planning. The role supports accurate documentation for reimbursement, collaborates with providers, payers, and care teams, and helps align patient care with quality and regulatory standards.

The UR Nurse improves hospital efficiency and patient outcomes while working within CMS and Joint Commission guidelines.

Qualifications

• Bachelor’s Degree in Nursing required and active RN license.
• Valid BLS certification maintained throughout employment.
• Three years of direct patient care experience, with 2 years inpatient.
• Knowledge of case management, U/L and utilization review concepts.
• Experience with electronic health records and clinical criteria sets.

Responsibilities

• Adheres to Case Management Standards of Practice and ANA standards.
• Coordinate assessments, service planning, and enrollment.
• Collaborate with care teams for discharge planning and referrals.
• Utilize UM data and guidelines (MCG) to determine appropriate care.
• Review precertifications for medical necessity across payors.
• Maintain clinical documentation accuracy and reporting for quality improvement.
• Communicate with physicians and payors to optimize patient care and reimbursement.
• Support continuity of care and patient advocacy across the care continuum.
• Ensure compliance with CMS and Joint Commission requirements.

Skills

Positive working relationships

Ethical standards

Reliability and attendance

Verbal & written communication

Team management focus

Utilization review experience

Knowledge of MCG criteria

Interview performance

Background/reference checks

Fingerprint and medical screenings

Education

Bachelor’s Degree in Nursing

Tools

Electronic health records

Clincal documentation systems

Job description

Tuba City Regional Health Care Corporation seeks an experienced Utilization Review Nurse to verify medical necessity, monitor patient status, and coordinate discharge planning. The role supports accurate documentation for reimbursement, collaborates with providers, payers, and care teams, and helps align patient care with quality and regulatory standards.

The UR Nurse improves hospital efficiency and patient outcomes while working within CMS and Joint Commission guidelines.