Utilization Review RN - Sign on eligible

Navajo Preference Employment Act

In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affi

Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.

The Utilization Review (UR) Nurse ensures that patients receive appropriate care by verifying medical necessity, confirming the correct patient status, and monitoring the ongoing need for services while working to reduce unnecessary length of stay and prevent delays; they support accurate clinical documentation for proper reimbursement, coordinate with providers and the care team on discharge planning and transitions, manage resource use to control costs, communicate with payers to prevent denials, and ensure compliance with CMS and Joint Commission requirements while contributing to reporting and quality improvement efforts.

They also serve as a key liaison between clinical care, finance, and regulatory requirements, helping align patient care with both quality standards and reimbursement rules. Ultimately, their role has a direct impact on patient outcomes, hospital efficiency, and the organization’s financial performance.

• Bachelor’s Degree in Nursing

• A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment

• Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care) {clinical experience qualification may be determined by hiring manager/director.}
• Demonstrate knowledge of case management, purchased referred care and utilization review
• Demonstrate knowledge of electronic health record systems.

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences
• Effective verbal & written communication skills
• Team management focus promoting a positive and pro-active approach to problem resolution
• Experience in hospital-based utilization review
• Proficient or experienced with clinical criteria sets for Miliman Care Guidelines(MCG)
• Completion of and receiving above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewers and TCRHCC that the applicant can perform the essential functions of the job
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of…