Utilization Review RN: Elevate Care & Compliance

St Mary Medical Center; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

St. Mary Medical Center seeks an Utilization Review Nurse to support the Utilization Management Hub. You will review medical records, authorize services, and prepare cases for physician review in collaboration with UM teams.

Successful candidates bring a clinical background with strong UM/regulatory knowledge and excellent analytical skills to ensure quality patient care, regulatory compliance, and responsible resource use in a fast-paced environment.

Qualifications

• Minimum two years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• California RN license.
• AHA BLS.
• Ability to pass annual Inter-rater reliability test for Utilization Review products used.
• Proficient in application of clinical guidelines (MCG/InterQual) preferred.
• Knowledge of managed care and payer environment preferred.
• Must have critical thinking and problem-solving skills.
• Collaborate effectively with multiple stakeholders.
• Professional communication skills.
• Understand how utilization management and case management programs integrate.
• Ability to work as a team player and assist other members of the team where needed.
• Thrive in a fast paced, self-directed environment.
• Knowledge of CMS standards and requirements.
• Proficient in prioritizing work and delegating where indicated.
• Highly organized with excellent time management skills.

Responsibilities

• Reviews admission and continued stay reviews per Care Coordination Utilization Review guidelines.
• Reviews the records for appropriate status and addresses deficiencies with providers.
• Communicates outcomes with physicians, payers, Care Coordinators and other stakeholders.
• Collaborates with RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated.

Skills

Critical thinking

Problem-solving

Professional communication

Collaboration

Time management

Organizational skills

Education

RN license (California)

Master's degree in Case Management or Nursing

CCM/ACM-RN/UM Certification

BSN preferred

Tools

MCG guidelines

InterQual guidelines

Job description

St. Mary Medical Center seeks an Utilization Review Nurse to support the Utilization Management Hub. You will review medical records, authorize services, and prepare cases for physician review in collaboration with UM teams.

Successful candidates bring a clinical background with strong UM/regulatory knowledge and excellent analytical skills to ensure quality patient care, regulatory compliance, and responsible resource use in a fast-paced environment.