Utilization Review RN

Utilization Review RN

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation's largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 158 hospital-based locations, in addition to its home-based services and virtual care offerings.

The Utilization Review RN is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking.

Additionally, as a Utilization Review RN, you will collaborate with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

In addition to bringing humankindness to the workplace each day, qualified candidates will need the following:

• Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.
• Utilization Review experience.
• Preferred graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.
• At least five (5) years of nursing experience
• RN license in the state(s) covered is required.

Physical Requirements - Medium Work - (Exert up to 50lbs force occasionally, and/or up to 20lbs frequently, and/or up to 10lbs constantly)

CommonSpirit Health is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.