Utilization Review RN - Impactful Care & Denials Management

Mosaic Life Care; Saint Joseph (MO); On-site; USD 70,000 - 95,000; Full time

Job summary

Mosaic Life Care in Missouri is seeking an experienced Utilization Review RN to evaluate inpatient and outpatient services for medical necessity, in collaboration with UM Specialists and Physician Advisors. The role focuses on reviewing admissions, discharges, denials, and appeals while ensuring compliant documentation and effective care transitions.

The ideal candidate holds an RN license in Missouri, with a BSN preferred, at least 3 years of clinical or managed care experience, and strong

Qualifications

• RN licensure in Missouri (or eligible)
• BSN preferred
• 3 years clinical or managed care experience
• Knowledge of medical necessity guidelines (CMS) preferred)
• Strong communication and teamwork skills

Responsibilities

• Conduct inpatient admission, concurrent, and retrospective reviews for Medicare/Medicaid and managed care patients
• Use CMS guidelines to determine appropriate level of care and communicate decisions to care team
• Stay current on regulatory changes affecting delivery or reimbursement
• Identify barriers to patient flow and communicate denials/appeals to team
• Collaborate with physicians and APRNs to ensure appropriate resource utilization and transitions of care
• Represent utilization management on committees and with external groups

Skills

Interdisciplinary collaboration

Communication skills

Education

Bachelor's degree (RN)

BSN - Preferred

Job description

Mosaic Life Care in Missouri is seeking an experienced Utilization Review RN to evaluate inpatient and outpatient services for medical necessity, in collaboration with UM Specialists and Physician Advisors. The role focuses on reviewing admissions, discharges, denials, and appeals while ensuring compliant documentation and effective care transitions.

The ideal candidate holds an RN license in Missouri, with a BSN preferred, at least 3 years of clinical or managed care experience, and strong