Utilization Management Specialist RN

Fairview Health Services • St. Paul, MN

14h • Remote

About The Position

Fairview is hiring a Utilization Management Specialist RN for a fully remote position at 0.6 FTE. The role ensures patients receive the appropriate level of care while supporting quality outcomes and reimbursement accuracy. The specialist uses acute care and utilization review expertise to assess medical necessity, obtain authorizations, manage payer denials and appeals, and collaborate with physicians and interdisciplinary teams across the health system.

Requirements

• Bachelor’s degree in Nursing.
• At least 3 years of Utilization Review or Case Management experience in a hospital, clinic, insurance company, or long-term care facility.
• At least 1 year of acute care hospital nursing experience.
• Minnesota Registered Nurse (RN) license.

Nice To Haves

• At least 1 year of Epic experience.
• At least 1 year of experience using medical necessity screening criteria such as InterQual or MCG.
• At least 3 years of acute care hospital nursing experience.
• Excellent computer and database management skills.

Responsibilities

• Perform and document timely, accurate utilization management reviews in compliance with policies, procedures, and regulatory and accreditation requirements.
• Use nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to assess level of care, length of stay, and discharge planning.
• Facilitate secondary physician reviews with the physician advisor and/or attending physician when required to support accurate level-of-care assignment and reimbursement.
• Resolve concurrent payer denials by submitting and coordinating medical-necessity appeals, and track denial- and appeal-related work.
• Educate internal healthcare team members about utilization management workflows and managed care concepts.
• Work on special projects and perform other duties as assigned by the Utilization Review Manager or Supervisor.
• Monitor and focus on key performance indicators.
• Contribute to processes that enable collection of expected reimbursement.
• Understand and follow Revenue Cycle’s Escalation Policy.

Benefits

• Medical, dental, and vision plans.
• Life insurance.
• Short-term and long-term disability insurance.
• PTO and Sick and Safe Time.
• Tuition reimbursement.
• Retirement benefits.
• Early access to earned wages.

What This Job Offers

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