Utilization Review RN

CommonSpirit Health • Omaha, NE

2d

About The Position

As our Utilization Review RN, you will play a pivotal role in optimizing healthcare delivery by ensuring medical necessity and appropriate patient status throughout the hospitalization journey. You will serve as a clinical expert, collaborating with attending physicians, consultants, and care coordination teams to apply evidence-based guidelines—such as MCG or InterQual—to facilitate seamless patient care transitions. Your expertise in managed care environments and CMS standards will be essential in navigating payer requirements, preventing claim denials, and upholding the high-quality standards of our health system. Every day you will perform comprehensive admission and concurrent stay reviews to validate the clinical necessity of care, ensuring every patient interaction is documented with precision. You will engage in proactive denial prevention strategies, coordinate peer-to-peer reviews between providers and insurance payers, and communicate critical status updates to stakeholders. By balancing clinical data analysis with professional communication, you will ensure our facility remains compliant with regulatory agencies and Joint Commission standards while supporting the overall progression of care for our diverse patient population.

Requirements

• Active Registered Nurse (RN) license in NE or IA.
• At least two years of acute hospital clinical experience.
• Detail-oriented professional.
• Strong grasp of utilization management programs.
• Excellent time management skills.
• Ability to thrive in a fast-paced, self-directed environment.
• Proficiency in clinical criteria application.
• Collaborative mindset.
• Commitment to organizational mission and core values.
• Graduate of an accredited school of nursing.
• 1-3 years Minimum two (2) years of acute hospital clinical experience, upon hire or Masters Other In Case Management or Nursing field in lieu of 1 year experience., upon hire
• Registered Nurse: NE, upon hire or Registered Nurse: IA, upon hire

Nice To Haves

• Bachelors Of Science BSN in Nursing or related healthcare field
• Five years of nursing experience, upon hire
• Certified Case Manager, upon hire
• Accredited Case Manager, upon hire

Responsibilities

• Perform comprehensive admission and concurrent stay reviews to validate the clinical necessity of care.
• Ensure every patient interaction is documented with precision.
• Engage in proactive denial prevention strategies.
• Coordinate peer-to-peer reviews between providers and insurance payers.
• Communicate critical status updates to stakeholders.
• Ensure facility remains compliant with regulatory agencies and Joint Commission standards.
• Support the overall progression of care for our diverse patient population.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree