Utilization Review RN

CommonSpirit Health • Houston, TX

1d • Onsite

About The Position

As our Utilization Management Professional, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision-making, regulatory compliance, and responsible resource utilization. Every day, you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria. To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow.

Requirements

• Diploma Of Nursing
• Graduate of an accredited school of nursing, upon hire
• Minimum two (2) years of acute hospital clinical experience, upon hire
• Registered Nurse: TX, upon hire

Nice To Haves

• Bachelors Of Nursing
• Bachelor's Degree in Nursing (BSN) or related healthcare field, upon hire
• At least five (5) years of nursing experience, upon hire
• Certified Case Manager, upon hire
• Accredited Case Manager, upon hire

Responsibilities

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.
• Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees