Registered Nurse - Utilization Review, PRN

Trinity Health • Mishawaka, IN

1d • Hybrid

About The Position

This is a remote, PRN position but will need onsite training in Mishawaka Indiana. The shift is Days - 8 hr shift. This role involves conducting clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types. The nurse will apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance. Collaboration with physicians, nursing staff, and interdisciplinary teams is essential to ensure appropriate resource utilization and care planning. The position also involves reviewing admissions and ongoing patient cases, recommending or escalating cases that do not meet criteria, and facilitating timely discharges, transfers, and recertifications. Partnering with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes, responding to denials, and identifying utilization concerns are key responsibilities. The role requires maintaining accurate records, compiling reports, providing education to clinical staff, and supporting compliance with all regulatory, accreditation, and organizational standards. Participation in committee meetings and assisting in the development of utilization review plans and processes is also expected.

Requirements

• Graduate of an accredited Registered Nurse (RN) program
• Active RN license (state-specific requirement applies)
• Minimum of 2 years of acute care nursing experience
• Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
• Solid understanding of clinical care practices, diagnoses, treatment modalities, and hospital operations
• Excellent communication skills with the ability to collaborate effectively across teams
• Strong analytical and critical thinking skills to assess clinical appropriateness and compliance
• Proficiency in computer systems and Microsoft Office applications
• Ability to manage multiple priorities in a fast-paced healthcare environment
• Flexibility to adapt to changing schedules, workflows, and departmental needs

Nice To Haves

• Bachelor’s Degree in Nursing preferred
• Prior utilization review, case management, or payer review experience preferred

Responsibilities

• Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
• Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
• Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
• Review admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review Committee
• Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
• Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
• Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
• Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
• Maintain accurate records, compile reports, and support utilization review program operations
• Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
• Support compliance with all regulatory, accreditation, and organizational standards
• Participate in committee meetings and assist in development of utilization review plans and processes

Benefits

• Tuition reimbursement for all full-time and part-time colleagues starting on day one
• Comprehensive benefits beginning day one (Medical, Dental, Vision, PTO, Life Insurance, STD/LTD, and more)
• Retirement savings plan with employer match
• Generous paid time off program plus 7 paid holidays
• Employee referral incentive program
• Access to state-of-the-art equipment, unlimited CEUs, and a supportive team-focused work environment

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level