Registered Nurse - Utilization Review

Trinity HealthMishawaka, IN
Remote

About The Position

This is a remote position but will need onsite training in Mishawaka Indiana. Shift: PRN/Days - 8 hr shift Considering local candidates only!!!

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
  • No mandatory overtime
  • Employee referral incentive program
  • Access to state-of-the-art equipment, unlimited CEUs, and a supportive team-focused work environment
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