Utilization Review RN: Optimize Care & Reimbursement

Tuba City Regional Health Care Corporation (TCRHCC); Tuba City (AZ); On-site; USD 75,000 - 105,000; Full time

Job summary

Tuba City Regional Health Care Corporation (TCRHCC) seeks an Utilization Review Nurse to verify medical necessity, confirm patient status, and monitor ongoing service needs. The role supports documentation for proper reimbursement and collaborates with providers on discharge planning to optimize outcomes.

You will engage with payers, ensure regulatory compliance, and contribute to reporting and quality improvement. Minimum RN license, BLS, and 3 years of clinical nursing experience are required.

Qualifications

• Bachelor’s degree in nursing required.
• Current RN license in the U.S. or territories; BLS certification.
• 3 years of clinical nursing experience, including at least 2 years inpatient medical-surgical, PACU, ICU or similar.
• Knowledge of case management, purchased referred care and utilization review.
• Experience with electronic health record systems.

Responsibilities

• Verify medical necessity and patient status.
• Coordinate discharge planning and care transitions.
• Monitor resource use to control costs and prevent denials.
• Engage with payers to ensure proper reimbursement and prevent delays.
• Ensure compliance with CMS and Joint Commission requirements.
• Advise on documentation quality to improve reimbursement.

Skills

Case management

Utilization review

Electronic health records

Communication skills

Discharge planning

Education

Bachelor’s Degree in Nursing

Tools

EHR systems

MCG guidelines

Job description

Tuba City Regional Health Care Corporation (TCRHCC) seeks an Utilization Review Nurse to verify medical necessity, confirm patient status, and monitor ongoing service needs. The role supports documentation for proper reimbursement and collaborates with providers on discharge planning to optimize outcomes.

You will engage with payers, ensure regulatory compliance, and contribute to reporting and quality improvement. Minimum RN license, BLS, and 3 years of clinical nursing experience are required.