Utilization Review Nurse - Midwest Remote

Utilization Review Nurse (RN)

Neuropsychiatric Hospitals is looking for a Utilization Review Nurse (RN) to coordinate patients' services across the continuum of care by promoting effective utilization, monitoring health resources and elaborating with multidisciplinary teams. This position will support multiple hospitals both remotely and traveling onsite to the hospitals.

Location: REMOTE- We are looking for someone located in the Midwest area, with strong preference in Indiana, Michigan, or Ohio.

Benefits of joining NPH

• Competitive pay rates
• Medical, Dental, and Vision Insurance
• NPH 401(k) plan with up to 4% Company match
• Employee Assistance Program (EAP) Programs
• Generous PTO and Time Off Policy
• Special tuition offers through Capella University
• Work/life balance with great professional growth opportunities
• Employee Discounts through LifeMart

Responsibilities

• Coordinate and support the hospital's Utilization Review and Case Management program to ensure appropriate level of care, efficient resource use, and timely discharge planning.
• Review patient charts and clinical documentation to verify medical necessity, severity of illness, and compliance with regulatory and care guideline standards (InterQual and Milliman).
• Conduct admission, concurrent, and length-of-stay reviews and communicate with payors regarding precertification, concurrent reviews, and authorizations.
• Collaborate with physicians, nursing staff, medical records, and finance to ensure accurate documentation and appropriate reimbursement.
• Monitor patient progress and coordinate care management strategies to support positive patient outcomes and reduce unnecessary length of stay.
• Identify utilization trends or documentation gaps and recommend process improvements to enhance quality and financial outcomes.
• Participate in multidisciplinary care coordination meetings and communicate with internal teams, families, and external providers as needed.
• Prepare reports and maintain documentation related to utilization review, denial management, and regulatory compliance.
• Maintain knowledge of current regulatory, accreditation, and reimbursement requirements related to utilization management and case management.

Qualifications

• Education: High School Diploma or GED and graduate from an accredited LPN program or Associate Degree in Nursing required. Bachelor or Masters of Science in Nursing or Behavioral Health field preferred.
• Experience: Minimum of 4 years of utilization review experience in a hospital setting required. Minimum of 2 years of case management experience, including discharge planning in a hospital setting preferred.
• Licensure: Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the state of practice required. Certified Case Manager (CCM), or Accredited Case Manager (ACM) preferred.
• Ability to work independently and collaboratively within a multidisciplinary team environment.
• Strong organizational and time management skills with the ability to prioritize tasks and manage a changing workload.
• Ability to analyze patient care data, develop criteria, and apply patient care methodologies.
• Experience abstracting and presenting data in a clear, professional manner for medical committees or leadership.
• Strong attention to detail with accurate documentation and data entry skills.
• Ability to maintain strict confidentiality and protect patient privacy.
• Ability to build and maintain effective working relationships with physicians, clinical staff, medical records personnel, social workers, patients, and the public.
• Strong communication skills, both written and verbal, including the ability to explain clinical and case management information to patients, families, and healthcare providers.
• Knowledge of care management plans, critical pathways, and case management practices.
• Knowledge of healthcare regulations and accreditation standards, including Case Management, Utilization Management, Risk Management, and HFAP/JCAHO requirements.
• Familiarity with hospital policies, medical staff bylaws, and community resources.
• Proficiency with Microsoft Office applications, email, and computer systems.
• Strong problem-solving and basic research skills.
• Knowledge of medications and patient care management practices.
• Travel flexibility up to 50–70% as required.