Utilization Review RN - Optimize Care & Denial Prevention

CHI; Omaha (NE); On-site; USD 47,000 - 68,000; Full time

Job summary

CommonSpirit Health is seeking a Utilization Review RN to optimize hospital care by applying evidence-based criteria (MCG/InterQual) and ensuring appropriate patient status. You will collaborate with physicians and care teams to prevent denials and support transitions, maintaining high standards of documentation and regulatory compliance.

The role requires an active RN license in NE or IA with at least two years’ acute hospital experience, and a strong grasp of utilization management in a

Qualifications

• Active RN license in NE or IA at hire.
• 2+ years acute hospital clinical experience required.
• Master's in Case Management or Nursing preferred or equivalent.

Responsibilities

• Conduct admission and concurrent stay reviews to validate clinical necessity.
• Perform denial prevention activities and optimize payer acceptance.
• Coordinate peer-to-peer reviews between providers and payers.
• Communicate critical status updates to stakeholders and ensure regulatory compliance.

Skills

Utilization management

Clinical collaboration

Documentation accuracy

Communication with stakeholders

Education

RN license NE/IA

Master's in Case Management or Nursing

Certified Case Manager (CCM)

Accredited Case Manager

Tools

MCG guidelines

InterQual guidelines

Job description

CommonSpirit Health is seeking a Utilization Review RN to optimize hospital care by applying evidence-based criteria (MCG/InterQual) and ensuring appropriate patient status. You will collaborate with physicians and care teams to prevent denials and support transitions, maintaining high standards of documentation and regulatory compliance.

The role requires an active RN license in NE or IA with at least two years’ acute hospital experience, and a strong grasp of utilization management in a