Utilization Review Nurse (Corporate Office)

Baptist Health

1d • Onsite

About The Position

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties. To learn more about Baptist Health, visit us at https://www.baptistfirst.org. Highlights: The Utilization Review Nurse is a key member of the centralized corporate Utilization Management Department, responsible for ensuring that patient care services are delivered efficiently, appropriately, and in alignment with payer requirements. Working within a department structured by payer-specific teams, this role conducts clinical reviews, validates medical necessity, and facilitates authorization processes across a defined portfolio of insurance plans. The Utilization Review Nurse collaborates closely with discharge planners, clinical providers, and payer representatives to support timely authorizations, minimize denials, and promote optimal patient flow. The nurse applies strong clinical judgment, detailed knowledge of payer policies, and evidence-based criteria to ensure compliance with regulatory standards and organizational goals. This position plays a critical part in advancing quality outcomes, supporting revenue integrity, and strengthening the organization’s relationship with contracted payers, all while operating from the corporate office in a structured, highly coordinated review environment. RN Case Management Summary: The RN – Case Management will be utilized as either Utilization Management or as Discharge Planning. The Case Manager tasked with discharge planning shall coordinate care of an assigned caseload of patients through collaboration with physicians, nursing staff, and other health professionals to facilitate efficient utilization of clinical resources, optimal clinical and continuing care, as well as financial outcomes. This individual shall be responsible for providing a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive human service needs through communication and available resources. The Case Manager tasked with utilization management shall work in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payers), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. This individual shall work collaboratively with other Clinical Care staff to ensure patient needs are met and care delivery is coordinated across the continuum. The RN will complete admission, continued stay, and discharge reviews in accordance with federal regulations, Insurance guidelines and Baptist Health's Utilization Management Plan. In addition, the RN is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This position may have additional duties assigned that are within scope of the role.

Requirements

• Degree in Nursing, Bachelor's degree preferred.
• At least 2 years hospital patient care experienced required.
• Previous experience in home care, reimbursement, or hospital insurance preferred.
• Previous inpatient hospital case management experience including utilization review (third party payor reimbursement, DRGs), and home care.
• Active RN license required, Case Manager certification preferred
• Must possess basic computer skills.
• Strong oral, written and interpersonal skills.
• Ability to work independently with minimal supervision.
• Must be able to function in high-stress environment subject to frequent interruptions and changing priorities.
• Knowledgeable in use of appropriate infection control or isolation techniques when necessary.
• Position requires sitting and mobility with occasional stooping, bending, kneeling, and crouching.
• There is frequent reaching, use of hands and repetitive action.
• Requires occasional lifting or carrying up to 20 pounds.
• There is a continuous need for speaking with clear diction and hearing sensitivity in conversation either by phone or in person.
• Continuous visual acuity at close and distant range.
• Inside protected from weather conditions but not necessarily from temperature changes.
• Minimal noise levels but frequent interruptions.
• Much exposure to computer work.
• Occasional exposure to risk of electrical shock.
• Some exposure to infectious disease while performing job-related tasks.
• Some exposure to hazardous chemicals.
• Occasional exposure to radiation.
• Ability to travel to seminars when required.
• Weekend and holiday work required.
• On-Call work required for after hours, weekends, and holidays.

Nice To Haves

• Degree in Nursing, Bachelor's degree preferred.
• Previous experience in home care, reimbursement, or hospital insurance preferred.
• Previous inpatient hospital case management experience including utilization review (third party payor reimbursement, DRGs), and home care.
• Case Manager certification preferred

What This Job Offers

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