Rn Utilization Review Jobs

About The Position

Requirements

• Bachelor’s degree in healthcare administration, nursing, health informatics, business, or a related field.
• Five years of management experience will be considered in lieu of degree.
• Three (3) years of experience in direct patient care RN experience in an acute care environment.
• Five (5) years of experience in Utilization Review or Case Management department performing utilization review activities, with at least two (2) years of utilization review for an acute care environment.
• Experience with Epic EMR is required.
• If the degree is in Nursing, an active RN license is required

Nice To Haves

• Master’s degree
• Certified Professional Coder CPC preferred.
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) within 2 years of eligibility.

Responsibilities

• Supervise the performance of Utilization Review, Revenue Integrity, and CDM team members
• Evaluate staff performance and productivity to ensure optimal use of resources
• Direct the overall activities of the Utilization Review team and implement efficiency measures
• Develop and achieve departmental goals and objectives to ensure organization metric goals are achieved
• Perform random audits to ensure appropriateness and timeliness of Utilization Review activities
• Monitor documentation in the software platforms for appropriate use
• Work closely with peers and leadership team to ensure the timely resolution of issues
• Maintain data and metrics to submit to the Revenue Cycle Committee
• Report and develop timely reports to submit to the Utilization Management Committee as directed
• Review Utilization Review plans annually, revising as necessary, and submit for approval by the Utilization Committee and Medical Executive Committee
• Assist with development and maintenance of department budget and ensure that the department operates within the allocated funds
• Manages all appeals related to denials for all payers
• Implement strategies to reduce denials while optimizing revenue
• Ensure all hospitalized patients have the correct admission status so that an appropriate claim can be submitted to the payer
• Oversee and coordinate the Utilization Review program's development to include the hospital resources as necessary to support its success
• Facilitate and foster staff and physician participation in the development and/or process revenue cycle operations
• Engage in improvement activities and events that maximize financial support for the hospital
• Communicate Utilization Review results through appropriate committees
• Develop and implement a continuous process improvement plan

Benefits

• Medical, Dental & Vision Coverage
• Multiple medical plan options through Aetna, including HSA‑eligible plans
• Tiered provider network with lower out‑of‑pocket costs for CRH providers
• Prescription drug coverage and access to CRH pharmacy services
• Comprehensive dental and vision plans
• On‑site Quick Care Clinic and virtual care options
• Employee‑only GLP‑1 Weight Loss Management Program (for eligible participants)
• Smoking cessation, chronic disease management, and fitness programs
• On‑site fitness center and wellness incentives through the HEALTHYme program
• Retirement savings plans with employer match and vesting
• Employer‑funded Health Savings Account (HSA) contributions (for eligible plans)
• Financial wellness coaching and planning resources through UBS
• Flexible Spending Accounts (Healthcare and Dependent Care)
• Generous Paid Annual Leave (PAL) with rollover options
• Observed paid holidays
• Short‑ and long‑term disability coverage (employer-paid for eligible roles)
• Employer‑paid life insurance and AD&D coverage
• Optional voluntary life insurance for employees and dependents
• Employee Assistance Program (EAP) with confidential counseling and legal/financial support
• Critical illness, accident, and hospital indemnity plans
• Identity theft protection, legal resources, and pet insurance