Utilization Review WEO RN

CoxHealth; Missouri; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Vision insurance

Dental insurance

Employer retirement match

Job summary

CoxHealth is seeking a Utilization Review Nurse (RN) to collaborate with physicians and a multidisciplinary team to ensure high-quality, cost-effective patient care. The role focuses on concurrent medical record reviews to assess medical necessity and level of care, determining inpatient vs observation needs, and communicating findings to payers.

Required: Missouri RN license with hospital experience; preferred: Bachelor's in Nursing and CCM certification.

Qualifications

• Graduate of an accredited nursing program.
• Preferred: Bachelor’s degree in Nursing with knowledge of InterQual Criteria and Milliman guidelines.
• Minimum of 3 years hospital experience.
• Current RN license active in Missouri.
• Preferred: Certified Case Manager.

Responsibilities

• Collaborate with physicians and multidisciplinary team to facilitate progression of care.
• Monitor patient progress to ensure plans are patient-focused, high-quality, and cost-effective.
• Conduct concurrent medical record reviews for medical necessity and level of care.
• Determine appropriateness of inpatient vs observation services and communicate with payers.
• Educate physicians and staff on resource utilization and coverage determinations.

Skills

Interpersonal skills

Communication skills

Team collaboration

Medical terminology

Education

Graduate of accredited School of Nursing

Bachelor's degree in Nursing (preferred)

Tools

InterQual Criteria

Milliman Care Guidelines

Job description

Facility: Remote Missouri: 1423 North Jefferson Avenue, Springfield, Missouri, United States of America, 65802 Department: 1665 Utilization Review Scheduled Weekly Hours: 40 Hours: 7:00 AM-5:30 PM Work Shift: Day Shift (United States of America)

CoxHealth is a leading healthcare system serving 25 counties across southwest Missouri and northern Arkansas. The organization includes six hospitals, 5 ERs, and over 80 clinics. CoxHealth has earned the following honors for workplace excellence: Named one of Modern Healthcare's Best Places to work five times. Named one of America's Greatest Workplaces, Greatest Workplaces in Healthcare (2025, 2026), Greatest Workplaces for Women (2023, 2024), and Greatest Workplaces for Diversity (2024) by Newsweek and Plant-A Insights Group. Acknowledged by Forbes as one of the Best Employers for New Grads. Healthcare Innovation's Top Companies to Work for in Healthcare (2025).

Benefits Medical, Vision, Dental, Retirement with Employer Match and more (20+ hrs/week)

The Utilization Review Nurse RN collaborates with the physician and members of the multidisciplinary team to facilitate progression-of-care; monitors the patient's progress, intervening appropriately to ensure that the plan of care and services provided are patient focused, high quality, evidence based, appropriate to patient needs, efficient, and cost effective. Conduct concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, accrediting bodies, and other state agencies. Prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines and insurance benefits and communicates information to payers in accordance with contractual obligations. Serve as a resource to the physicians and provide education and information on resource utilization, national and local coverage determinations, and use of hospital admission criteria.

Education

• Required: Graduate of an accredited school of nursing
• Preferred: Bachelor's of Nursing with knowledge of InterQual Level of Care Criteria and/or Milliman Care Guidelines and of local/national coverage determinations

Experience

• Minimum of 3 years hospital experience

Skills

• Excellent interpersonal skills, including ability to be genuine and empathetic
• Excellent communication (verbal and written) skills with attention to detail
• Computer skills
• Ability to interact professionally and contribute to the interdisciplinary team

Licensure/Certification/Registration

• Current RN License active in the state of Missouri
• Preferred: Certified Case Manager

Are you ready to make a meaningful impact in your community?

At CoxHealth, we don't just provide medical services; we've created an atmosphere where innovation, collaboration, values, and excellence come together to transform lives. Whether you desire to work in a clinical or non-clinical capacity, CoxHealth has the perfect position for you!

CoxHealth is the region's employer of choice because we keep our mission, vision, and values in mind with every decision for our employees and our patients.

OUR MISSION To improve the health of the communities we serve.

OUR VISION To be the best for those who need us.

OUR VALUES Safety, compassion, respect, and integrity.

Join our Talent Network and our recruitment team will get in touch if there's a role that seems like a good match.

CoxHealth is the area leader in health care and community involvement, with six hospitals, more than 80 clinics, five ERs and more than 14,000 employees throughout southwest Missouri. We offer a wide range of treatments and services to help with whatever health needs you might have. Whether you're about to become a parent, have an illness or need medical information, we're here for you. And if your goal is to live a healthy, balanced life with the best tools available, we can help with that, too. We know that your health and the health of your loved ones are some of the most personal, important parts of your life. That's why we keep our Mission, Vision and Values at the center of everything we do, every day.

Thank you for choosing CoxHealth.