Utilization Review Nurse; RN
Listed on 2026-01-16
-
Nursing
Healthcare Nursing, Clinical Nurse Specialist
- Salary Range : $63,190.40 USD to $94,785.60 USD
Showing 1 location
Midtown Hospital
600 Mary St
Evansville, IN 47710, USA
Midtown Hospital
600 Mary St
Evansville, IN 47710, USA
Eligible for evening/night, weekend shift incentive based on company policies and applicable job codes. Additional details will be provided during the interview process.
Bonus:
Potential for a performance-based bonus, subject to eligibility criteria and achievement of defined metrics. Details regarding bonus eligibility and performance goals will be provided during the interview process or upon hire.
We pride ourselves in retaining our top talent by offering work environments that support professional development and personal success. In addition to our robust healthcare and retirement plans, we offer:
- Payactiv-earned wage benefit-work today, get paid tomorrow
The Utilization Management RN helps drive change in system throughput by working alongside the clinical care teams and communicating to the Case Management teams on case medical necessity criteria and appropriateness of bed status. These RNs are responsible for performing initial clinical patient reviews on all patients presenting to the acute care hospitals, behavioral health units, critical access hospitals and/or Emergency Departments, if admission is being considered, within the Deaconess Health System.
The Utilization Management RN assesses medical necessity and appropriate level of care for the hospital observation or admission based on screening tools and criteria. Applies clinical expertise in monitoring, evaluating, coordinating, and performing concurrent reviews. Communicates with other members of interdisciplinary team to discuss level of care and utilization of hospital resources are appropriate to criteria and patients' hospital needs, and communicates any payer authorization issues, considerations for discharge transition or denial of care.
Maintains current knowledge of payer requirements and patterns and educates physicians, case managers, social work, nursing and others to assure compliance. Involved in review of clinical denialsки ọbụ and preparing written appeals as needed with a goal towards successful outcome and reversal. Documents all pertinent information into utilization review software that may include clinical denials database, EMR, or Patient Billing system for tracking, managing and reporting outcomes of appeals.
Is astute to payer review, approval and denial practices and patterns, and identifies opportunities to address improvement to avoid fiscal denials. Maintains client confidentiality and adheres to ethical, legal and accreditation/regulatory standards.
Required:
Certifications/Licenses/
Experience:
- Active Registered Nurse (RN) in Indiana or other compact licensure state
- Three (3) years of acute care experience
- Preferred on medical/surgical unit, emergency room or intensive care unit
Preferred Certification/License/
Experience:
- BSN
Case Management certification - ANCC
Case Management certification - ACM-RN
Case Management certification - CCM
- Prior UR experience with familiarity of prospective payment diagnosis related groups (DRG) and principles of reimbursement or insurance industry including Federal and State UR compliance standards
Other Key Words: Registered Nurse // UM //立 Denials // Chart Review
Campus: Midtown
Hours: Full-time, 40 hours/week
Equal Opportunity Employer
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