Utilization Review Nurse Jobs

About The Position

Requirements

• Active, unencumbered Registered Nurse (RN) license in Colorado or Compact-state license that includes Colorado.
• Two (2) to three (3) years’ of recent clinical experience in an acute care setting required.
• Strong knowledge of Medicare, Medicaid, and commercial payer regulations, as well as medical necessity criteria (e.g., InterQual, Milliman Care Guidelines).

Nice To Haves

• Previous experience in managing staff and schedules required.
• One (1) year of experience in Utilization Review or Case Management preferred.

Responsibilities

• Perform concurrent and retrospective utilization reviews for all patient admissions and continued stays, applying established medical necessity criteria (e.g. InterQual, Milliman Care Guidelines), and payer specific guidelines.
• Communicate effectively with attending physicians, residents, and other healthcare providers regarding medical necessity, documentation requirements, and alternative levels of care.
• Identify and address potential barriers to discharge, collaborating with the Case Management team to facilitate timely patient progression.
• Document all review activities, including approvals, denials, and appeals processes, accurately and thoroughly in the electronic health record (EHR) system.
• Assist in the preparation and submission of appeals for denied services, providing clinical rationale and supporting documentation.
• Stay current with Medicare, Medicaid, and commercial payer regulations, policies, and medical necessity criteria.
• Collaborate with the Case Management team to ensure seamless coordination between utilization review and discharge planning activities.
• Participate in interdisciplinary team meetings to discuss patient status, care progression, and discharge readiness.
• Provide education to physicians and other staff on documentation requirements for medical necessity.
• Monitor readmissions and avoidable days in Meditech for quality improvement initiatives.
• Coordinate in advance discharge planning for orthopedic surgical patients, ensuring timely referrals, equipment orders, and post-discharge services.
• Actively participate in the Utilization Review (UR) Committee.
• Perform other duties as assigned to support utilization management, case management, and hospital operations.
• Other duties as assigned.