Registered Nurse – Utilization Review, Per Diem

This is a fully remote position, open to applicants in Arizona.

📋 Description

• Evaluate and oversee the utilization of healthcare services to ensure high-quality and cost-effective care.

• Conduct thorough medical necessity assessments for extended stays, outpatient observation, inpatient admissions, and ancillary services.

• Coordinate and carry out reviews for Medicare, AHCCCS, self-pay, and other insurers upon admission and continuously throughout the stay.

• Analyze clinical documentation and facilitate modifications to accurately represent the level of service and severity of illness.

• Execute initial and concurrent reviews for patients entering the healthcare continuum.

• Support the delivery of services through efficient utilization of available resources.

• Conduct medical record reviews as mandated by payers.

• Collaborate with the Care Management team regarding quality outcome metrics.

• Partner with physicians, case managers, payers, and others to challenge denials and address trending issues.

• Work alongside medical records, finance, and physician groups to enhance documentation and data reporting.

• Initiate chart reviews, complete follow-up assessments, and round on patients to ensure continuity in utilization review processes.

• Maintain systems that identify admissions based on diagnosis, DRG classifications, and other categories.

• Inform physicians and relevant staff about documentation concerns requiring clarification.

• Assess qualifications for hospital-level care using established criteria.

• Perform additional duties as assigned.

⛳️ Requirements

• Associate's Degree in Nursing from an accredited NLN/CCNE institution - Required.

• Bachelor's Degree in Nursing from an accredited NLN/CCNE institution - Preferred.

• Minimum of 1 year experience in Utilization Review (UR), Utilization Management (UM), or Case Management - Required.

• At least 3 years of Registered Nurse experience in an acute care environment - Required.

• Valid Registered Nurse (RN) State and/or Compact State Licensure - Required.

• Certified Case Management (ACM) Case Management Certification - Preferred.

• Knowledge of medical necessity and utilization review processes.

• Proficiency in reviewing clinical documentation and medical records.

• Familiarity with Medicare, AHCCCS, self-pay, and other payer requirements.

• Capability to determine qualifications for hospital-level care using established criteria.

• Ability to collaborate effectively with physicians, case managers, payers, and other stakeholders.

• Availability for day shifts, 7:30–4:00, with team operations from Monday through Sunday.

• Option for remote work after training.

🏝️ Benefits

• Remote work option after training.

• Day shift hours from 7:30–4:00.

• PRN/per diem scheduling available.