RN Utilization Review Case Manager

Gateway Regional Medical Center•Granite City, IL

1d•Onsite

About The Position

The Utilization Review Specialist RN assumes responsibility and accountability for admission and concurrent reviews to ensure the prevention of denials from all payers, as well as coordination and management of appeals for accounts deemed appropriate for appeal. This role supports compliance with payer, regulatory, and accreditation standards while promoting efficient utilization of healthcare resources and quality patient outcomes. The Specialist works collaboratively with interdisciplinary teams to identify denial trends, improve workflows, and ensure timely resolution of utilization review and appeals processes.

Requirements

Graduate of an Accredited School of Professional Nursing
Current Illinois Nursing License
Current Basic Life Support (AHA or American Red Cross BLS) certification
Minimum of five years of clinical nursing experience in an acute care setting required.

Nice To Haves

Knowledge of InterQual and/or Milliman criteria
Experience in case management, discharge planning, utilization review, or appeals management preferred.

Responsibilities

Assumes responsibility and accountability for admission and concurrent reviews to ensure the prevention of denials from all payers.
Coordinates and manages appeals for accounts deemed appropriate for appeal.
Supports compliance with payer, regulatory, and accreditation standards.
Promotes efficient utilization of healthcare resources and quality patient outcomes.
Works collaboratively with interdisciplinary teams to identify denial trends, improve workflows, and ensure timely resolution of utilization review and appeals processes.