Utilization Review RN

Longmont United Hospital•Longmont, CO

1d•$39 - $58

About The Position

The Utilization Review RN reviews medical records to determine appropriate admission status and continued hospitalization using established criteria and clinical judgment. The role conducts admission, concurrent, and post-discharge reviews; verifies appropriate patient status orders; and communicates review outcomes to physicians, payers, Care Coordinators, and other stakeholders. The RN collaborates with Patient Access to verify payer sources and obtain inpatient authorizations, works with RN Care Coordinators to support care progression, and partners with Concurrent Denial RNs to identify denial causes and prevention strategies. The position also supports second-level physician review, coordinates peer-to-peer discussions, and documents a working DRG at initial review. Work must comply with utilization review principles, hospital policies, payer criteria, and applicable external regulatory requirements. Success requires critical thinking, problem-solving, strong professional communication, collaboration, attention to detail, and the ability to prioritize and manage time in a fast-paced, self-directed environment. The role also requires knowledge of utilization management, case management, CMS requirements, managed care, payer environments, and clinical guidelines.

Requirements

Associate's degree in Nursing.
At least two years of acute hospital clinical experience, or a master's degree in Case Management or a Nursing field in lieu of one year of experience.
Current state RN license or a valid RN license from a participating state in the National Licensure Compact.
Ability to pass the annual Interrater reliability test for the Utilization Review product(s) used.
Understanding of how utilization management and case management programs integrate.
Knowledge of CMS standards and requirements.
Critical-thinking and problem-solving skills, professional communication abilities, collaboration, attention to detail, and effective prioritization and time management.

Nice To Haves

Bachelor's degree in Nursing (BSN) or a related healthcare field.
At least five years of nursing experience.
Certified Case Manager (CCM), Accredited Case Manager (ACMRN), or UM certification.
Proficiency in applying clinical guidelines, including MCG or InterQual.
Knowledge of the managed care and payer environment.

Responsibilities

Conduct admission and continued-stay reviews according to Care Coordination Utilization Review guidelines and established criteria.
Perform admission, concurrent, and post-discharge reviews to determine appropriate patient status.
Ensure compliance with utilization review principles, hospital policies, external regulatory requirements, PRO, Joint Commission, and payer eligibility criteria.
Review records for accurate patient status orders and address deficiencies with providers.
Communicate and follow up promptly with physicians, payers, Care Coordinators, and other stakeholders regarding review outcomes.
Collaborate with facility RN Care Coordinators to support progression of care.
Engage internal or external second-level physician reviewers as indicated to support appropriate patient status.
Collaborate with Concurrent Denial RNs to identify denial causes and implement prevention strategies.
Work with Patient Access to verify payer sources and obtain inpatient authorization from insurance providers.
Support and coordinate peer-to-peer discussions.
Document a working DRG for each assigned patient at initial review.