Utilization Review Nurse - RN

Singing River Health System • Ocean Springs, MS

10d • Onsite

About The Position

The Utilization Review (UR) Nurse is responsible for ensuring that patient care services meet established medical necessity criteria and align with appropriate levels of care. This role performs concurrent and retrospective reviews to evaluate the appropriateness, quality, and efficiency of care based on the patient’s clinical presentation and services ordered or provided. Using established hospital approved level of care criteria and professional clinical judgment, the UR Nurse determines appropriate patient status and facilitates the use of the most suitable level of care. This role requires maintaining up-to-date knowledge of commercial and government payer requirements, as well as DNV regulations, guidelines, and criteria related to the Utilization Review process. The UR Nurse practices in accordance with professional Standards of Nursing Practice under the leadership and direction of the Utilization Management Director. This position demands the ability to work effectively in high-pressure environments, manage multiple tasks simultaneously with minimal errors, and function independently with strong attention to detail.

Requirements

• Graduate from an accredited school of Nursing: Bachelor’s degree in nursing preferred.
• Currently licensed to practice as a Nurse in the State of Mississippi.
• Five (5) years’ acute care nursing and/or case management experience.
• Proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word.
• Ability to demonstrate appropriate clinical judgment and apply appropriate professional skills to a patient population of all ages.

Nice To Haves

• ACMA (American Case Management Association) or CCM (Certified Case Manager) certification preferred.
• Utilization or Case Management experience preferred.

Responsibilities

• Ensuring that patient care services meet established medical necessity criteria and align with appropriate levels of care.
• Performing concurrent and retrospective reviews to evaluate the appropriateness, quality, and efficiency of care based on the patient’s clinical presentation and services ordered or provided.
• Determining appropriate patient status and facilitating the use of the most suitable level of care using established hospital approved level of care criteria and professional clinical judgment.
• Maintaining up-to-date knowledge of commercial and government payer requirements, as well as DNV regulations, guidelines, and criteria related to the Utilization Review process.
• Practicing in accordance with professional Standards of Nursing Practice under the leadership and direction of the Utilization Management Director.
• Working effectively in high-pressure environments.
• Managing multiple tasks simultaneously with minimal errors.
• Functioning independently with strong attention to detail.

What This Job Offers

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