Registered Nurse - Utilization Review

Job TitleEmployment Type: Full timeShift: Rotating ShiftDescription: This is a remote position but will need onsite training in Mishawaka Indiana. Shift: Days - 8 hr shift LOCAL CANDIDATES ONLY!Why Choose Saint Joseph Health System?At Saint Joseph Health System, our values guide every decision we make. Even when challenges arise, we remain committed to our mission: caring for every person who needs us. We invest in our people, our technology, and our capabilities so we can continue delivering exceptional, compassionate care to our communities.What We OfferTuition reimbursement for all full-time and part-time colleagues starting on day oneComprehensive benefits beginning day one (Medical, Dental, Vision, PTO, Life Insurance, STD/LTD, and more)Retirement savings plan with employer matchGenerous paid time off program plus 7 paid holidaysNo mandatory overtimeEmployee referral incentive programAccess to state-of-the-art equipment, unlimited CEUs, and a supportive team-focused work environmentWhat You Will DoConduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor typesApply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and complianceCollaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planningReview admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review CommitteeFacilitate timely discharges, transfers, and recertifications when level of care is no longer appropriatePartner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processesRespond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patientsIdentify trends and utilization concerns; contribute to performance improvement and quality initiativesMaintain accurate records, compile reports, and support utilization review program operationsProvide education to clinical staff on documentation requirements, coverage guidelines, and utilization processesSupport compliance with all regulatory, accreditation, and organizational standardsParticipate in committee meetings and assist in development of utilization review plans and processesWhat You Will NeedGraduate of an accredited Registered Nurse (RN) program; Bachelor's Degree in Nursing preferredActive RN license (state-specific requirement applies)Minimum of 2 years of acute care nursing experiencePrior utilization review, case management, or payer review experience preferredStrong knowledge of Medicare, Medicaid, and commercial insurance guidelinesSolid understanding of clinical care practices, diagnoses, treatment modalities, and hospital operationsExcellent communication skills with the ability to collaborate effectively across teamsStrong analytical and critical thinking skills to assess clinical appropriateness and complianceProficiency in computer systems and Microsoft Office applicationsAbility to manage multiple priorities in a fast-paced healthcare environmentFlexibility to adapt to changing schedules, workflows, and departmental needsOur CommitmentRooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.