Utilization Review RN

CommonSpirit Health • Longmont, CO

22h • Onsite

About The Position

The Utilization Review RN reviews medical records to confirm appropriate admission status and continued hospitalization using established criteria and clinical judgment. The role conducts admission, concurrent, and post-discharge reviews; verifies that hospitalization is warranted; and ensures compliance with utilization review principles, hospital policies, external regulatory requirements, and payer criteria. The RN reviews patient status orders, addresses deficiencies with providers, and communicates review outcomes promptly to physicians, payers, Care Coordinators, and other stakeholders.

The role collaborates with facility RN Care Coordinators to support progression of care and works with Concurrent Denial RNs to identify denial causes and develop prevention strategies. Responsibilities also include collaborating with Patient Access to verify payer sources, documenting interactions, obtaining inpatient authorization, supporting second-level physician review, coordinating peer-to-peer discussions, and documenting a working DRG on each assigned patient at initial review.

The successful candidate brings critical thinking and problem-solving skills, strong professional communication and collaboration abilities, attention to detail, and the capacity to prioritize and manage work in a fast-paced, self-directed environment. Knowledge of managed care and payer environments, utilization management and case management integration, CMS requirements, and clinical guidelines supports the organization’s commitment to quality care and fiscal responsibility.

The position is based at Longmont United Hospital in Longmont, Colorado. The hospital describes a supportive team and opportunities for cross-training and continuing education.

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 nursing license or a valid RN license from a participating state in the National Licensure Compact.
• Ability to pass the annual Interrater reliability test for Utilization Review products 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, collaboration, prioritization, delegation, time management, and attention to detail.

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/InterQual.
• Knowledge of the managed care and payer environment.

Responsibilities

• Conduct admission, concurrent, and post-discharge reviews to determine appropriate patient status and whether hospitalization is warranted, using established criteria and critical thinking.
• Ensure compliance with utilization review principles, hospital policies, external regulatory agencies, and payer-defined 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 status.
• Work with Concurrent Denial RNs to identify denial root causes and implement prevention strategies.
• Collaborate with Patient Access to verify payer sources, document interactions, and obtain inpatient authorization from insurance providers.
• Coordinate peer-to-peer discussions and document a working DRG on each assigned patient at initial review.

Benefits

• Cross-training opportunities.
• Continuing education opportunities.
• The posting describes flexibility and a supportive team that values self-care; specific benefit plans are not detailed.

What This Job Offers

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