Utilization Review RN Part-Time (Remote in Arizona)
About the position Responsibilities • Conducts medical necessity reviews for Medicare, Medicaid, self-pay, and other insured patients. • Verifies physician orders per Medicare and payer guidelines and ensures documentation reflects patient acuity accurately. • Coordinates with medical staff, Case Managers, and Insurance Specialists to facilitate clear communication with payers, ensuring timely, accurate information. • Consults with the Physician Advisor for complex cases and engages in denial management. • Documents utilization review activities in the MCG system, maintains complete records, and collaborates across teams for quality care. • Educates staff on clinical guidelines, utilization review, and payer regulations. • Assesses patient cases using nationally recognized criteria for admission and care level. • Collaborates with physicians to determine inpatient vs. observation status and performs Code 44 when necessary. • Identifies cases needing further intervention, considers appropriateness and quality, and communicates expected length of stay per Medicare guidelines. • Supports Case Managers and educates staff on CMS guidelines and documentation needs. • Protects patient rights, ensuring confidentiality and compliance with hospital policies. • Participates in committees and ongoing education, staying current with performance improvement and regulatory standards. Requirements • Must reside in Arizona to be eligible for remote work. • Graduate of an accredited nursing school. • Active Arizona or compact state RN license. • Must have 1+ years of Utilization Review experience, preferably in both clinical and managed care, and 3 years clinical experience (preferably med-surg/critical care). • Strong clinical knowledge, communication, problem-solving, and proficiency in standard office tools. • Ability to work with diverse teams and recognize quality care issues. • Excellent verbal and written communication, interpersonal skills, and ability to use standard office equipment/software. • Strong clinical skills and able to recognize quality issues, and knowledge of nationally recognized criteria used to make medical necessity determinations. • Effective problem solving, analyzing complex situations, draw conclusions and implement appropriate actions efficiently. • Ability to sit for 3-5 hours per day, stand 3-5 hours, and walk 3-5 hours. Benefits • Paid Sick Time • 403b Retirement Plan with Employer Contributions • Scholarship Program for qualified individuals pursuing a first degree in healthcare related field • On-Site Daycare, exclusive to our employees' children of all ages • Employee Discounts and Employee Referral Bonus Program • Eligibility for the Public Service Loan Forgiveness program for employees with qualified student loans Apply tot his job