Utilization Review Registered Nurse (RN) Part time

Position Summary
The Utilization Review RN is responsible for performing accurate and timely concurrent and retrospective reviews using established criteria to ensure appropriate utilization of healthcare resources. This role collaborates with physicians, hospital departments, and multidisciplinary teams to expedite care delivery, prevent delays, and maintain compliance with regulatory guidelines.

Major Responsibilities

• Document utilization review activities per department and medical center standards in a timely manner.
• Perform and document concurrent and retrospective reviews based on approved criteria.
• Communicate effectively with healthcare teams, including physicians and ancillary services, to support timely care delivery.
• Collaborate with managers, medical directors, and treatment teams to address utilization issues and ensure compliance.
• Refer cases to physician advisors as needed for accurate status determination.
• Stay current on healthcare regulations, reimbursement issues, and community resources.
• Provide clinical updates to payers, coordinate denial activity, and manage avoidable delays.
• Serve as an educator and resource for staff regarding admission status, acute care criteria, and regulatory requirements.
• Develop and maintain relationships with community agencies to support patient and family needs.
• Demonstrate age-specific care knowledge and skills across the patient lifespan.

Experience & Skills Required

• Working knowledge of Microsoft Office (Excel, Outlook, PowerPoint, Word).
• Understanding of quality and acute care patient needs related to care management.
• Knowledge of Utilization Review criteria; must achieve 80% or greater on annual IRR competency exam.
• Strong critical thinking skills for applying medical necessity criteria.
• Excellent analytical, communication, and interpersonal skills for interaction with patients, families, physicians, and payers.
• Ability to manage conflict and maintain positive professional relationships.
• Commitment to professional growth and participation in department and system initiatives.