RN - Utilization Review

Tuba City Regional • Tuba City, AZ

18h • Onsite

About The Position

The Utilization Review (UR) Nurse ensures that patients receive appropriate care by verifying medical necessity, confirming the correct patient status, and monitoring the ongoing need for services while working to reduce unnecessary length of stay and prevent delays; they support accurate clinical documentation for proper reimbursement, coordinate with providers and the care team on discharge planning and transitions, manage resource use to control costs, communicate with payers to prevent denials, and ensure compliance with CMS and Joint Commission requirements while contributing to reporting and quality improvement efforts. They also serve as a key liaison between clinical care, finance, and regulatory requirements, helping align patient care with both quality standards and reimbursement rules. Ultimately, their role has a direct impact on patient outcomes, hospital efficiency, and the organization's financial performance.

Requirements

• Bachelor’s Degree in Nursing.
• A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States.
• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment.
• Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care).
• Demonstrate knowledge of case management, purchased referred care and utilization review processes.
• Demonstrate knowledge of electronic health record systems.

Responsibilities

• Verify medical necessity and confirm correct patient status.
• Monitor ongoing need for services and reduce unnecessary length of stay.
• Support accurate clinical documentation for proper reimbursement.
• Coordinate with providers and care team on discharge planning and transitions.
• Manage resource use to control costs and communicate with payers to prevent denials.
• Ensure compliance with CMS and Joint Commission requirements.
• Contribute to reporting and quality improvement efforts.

What This Job Offers

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