Registered Nurse; RN Utilization Review – PRN

Role Overview: The Utilization Management Nurse (UM) Coordinator conducts 24/7 medical necessity reviews, utilizing clinical guidelines and documentation to determine appropriate levels of care. They communicate with payers, providers, and care teams to obtain authorizations, monitor patient progress, and facilitate safe care transitions.

• Perform daily clinical reviews of admissions, observation cases, and concurrent care using established criteria.
• Obtain timely authorizations, document activities accurately, and communicate with payers to resolve discrepancies.
• Monitor post-discharge accounts for authorization issues, variances, and denials, escalating as needed.
• Ensure compliance with payer and regulatory requirements, advocate for patients, and support continuous improvement initiatives.
• Complete thorough documentation and participate in professional development activities.

• Minimum 3 years of clinical practice with strong clinical knowledge.
• Associates or Bachelor’s Nursing degree preferred; RN license (single or multi-state), BLS certification required.
• Knowledge of case management, excellent communication, organizational, and critical thinking skills.
• Proficient in screening criteria, clinical data review, and computer use.

The role involves working PRN days, with responsibilities including assessments, documentation, collaboration with healthcare providers, and ensuring compliance with regulations. The position offers an opportunity to contribute to patient care quality while developing professionally within an integrated health system.