Utilization Review Nurse

Overview

University of Utah Health is a patient‑focused organization dedicated to enhancing health and well‑being through patient care, research, and education. This role supports the mission by ensuring financial integrity and quality patient care, focusing on medical necessity and efficient delivery. A culture of collaboration, excellence, leadership, and respect is essential.

EEO/AA

Corporate Overview:
The University of Utah is a Level 1 Trauma Center and is nationally recognized for academic research, quality standards, and overall patient experience. Five hospitals and eleven clinics provide comprehensive services and medical advancement.

• Apply approved utilization criteria to monitor appropriateness of admissions, levels of care, and ongoing stay review.
• Communicate with third‑party payers for initial and concurrent clinical review.
• Review patient charts to confirm continued medical necessity.
• Document all actions and information shared with care team members or payers.
• Alert and discuss with physician/provider and case manager/discharge planner when a patient no longer meets medical necessity criteria for inpatient stay.
• Discuss appropriateness of resource utilization with physicians.
• Track length of stay (LOS) and resource utilization to identify at‑risk patients.
• Refer cases that surpass expected LOS, cost, or resource utilization to the UR Committee.
• Conduct verbal/fax clinical reviews with payers as determined by nursing judgment and contractual obligations.
• Participate in the UR Committee as needed.
• Collect data on LOS variances, avoidable days, costs/barriers to discharge/transition, and denied days.
• Prepare appeals for denied cases when appropriate.
• Work rotating schedules (variable hours, weekends, nights, holidays) to meet 24/7 staffing and patient care demands. Regular, reliable, and punctual attendance during assigned shifts is essential.

• Availability to work variable and rotating shifts, including nights, weekends, and holidays in a 24/7 patient care environment.
• Ability to perform the essential functions outlined above.
• Team leadership, relationship building, critical analysis, and written and verbal communication skills.
• Knowledge of payers, payer systems, cost‑effective utilization management, and Inter Qual criteria.
• Understanding of life‑span growth and development principles to assess patient status and provide care per department policies.
• Autonomous and collaborative work style.

• One year of Utilization Review or Case Management experience.

• Current Registered Nurse license in the State of Utah, or ability to obtain one within 90 days of hire under the interstate compact if relocating to Utah. Must maintain current interstate compact (multi‑state) license if residency is not changed.
• Additional license requirements as determined by the hiring department.

• Basic Life Support Health Care Provider card.
• Proficiency in application of Inter Qual Criteria, knowledge of ICD‑9, DRG, and CPT codes.
• Utilization Review certification designation.
• Knowledge of CMS regulations.

• Sedentary office setting; may exert up to 10 pounds and lift, carry, push, pull, or otherwise move objects.
• Primarily seated; not exposed to adverse environmental conditions.
• Position does not provide direct patient care.

• Color determination, listening, manual dexterity, sitting, speaking, standing, walking.