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RN Utilization Management

Company: StCharles
Location: North Las Vegas
Posted on: November 12, 2021

Job Description:



TITLE:                                      RN Utilization Management

REPORTS TO POSITION:         Manager, Utilization Review

DEPARTMENT:                         Quality

DATE LAST REVIEWED:          September 12, 2017

OUR VISION:                Creating America’s healthiest community, together

OUR MISSION:             In the spirit of love and compassion, better health, better care, better value

OUR VALUES:              Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY: The Utilization Review Department provides many services to our multi-hospital organization including: Support to physicians and clinical staff in determining whether all aspects of a patient’s care, at every level is medically necessary and appropriately delivered. The Utilization Review department also acts to ensure compliance with the Medicare Conditions of Participation and capture of appropriate reimbursement for the health system.

POSITION OVERVIEW Under the supervision of the Manager/Director, Utilization Review, the Utilization Management RN completes clinical reviews of hospital admissions for medical necessity, utilizing InterQual criteria, so that revenue is fully and accurately captured for hospital stays.  Assures conformity to the federal and state government health care program requirements, the internal hospital utilization review process, and any third party payor utilization review processes or managed care process.  Works closely with physicians, nursing staff, insurance companies, patient registration, and patient financial services to accurately document medical necessity and admitting status for each admission. This position does not directly manage any other caregivers.


Performs clinical chart reviews for appropriateness and medical necessity of admissions, continued stays, and supportive services to promote quality care and full and accurate capture of revenue.

Following completion of clinical reviews for medical necessity of hospital stays, refers to second level review when necessary.

Communicates with the physicians, as needed to address issues of medical necessity and appropriate level of care -- and may provide support regarding Medicare documentation requirements. May obtain verbal admission orders from physicians and monitor for authorization by the physician. May participate in the delivery of regulatory forms to patients when appropriate.

Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays. 

Keeps patient registration and patient financial services informed of any changes in admission status, working towards accurate capture of admission status prior to the time the initial billing is sent.

Continually assesses clinical services for appropriateness for continued stay. 

Notifies case management of potential problematic cases.

Serves as a resource and actively provides education to physicians on inpatient and observation medical necessity criteria.

Participates with the Utilization Review Committee.

Quality of care issues are identified and reported through the EMS system or immediately if indicated, to risk management.

Has primary responsibility when medical necessity denials are received to complete an additional review and prepare and coordinate medical necessity appeals.  Works closely with compliance auditor to provide clinical reviews and appeals for RAC, CERT, and MAC denials and audits.

Serves as a clinical resource for non-nursing members of the Utilization Management department.

Participates in clinical care conferencing.

Documents actions taken in the patient financial record and performs clinical reviews using commercial review criteria.

Participates in tracking of departmental quality measures by entering data in the UM database for compilation.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. 

May perform additional duties of similar complexity within the organization, as required or assigned.


Required: Graduate of an accredited school of nursing             

Preferred: BSN            


Required: Current Oregon RN license    

Preferred: N/A 


Required:  Minimum 3 years of combined hospital related Utilization Review experience  

Preferred: N/A             


Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.




Ability to effectively interact and communicate with all levels within St. Charles Health System and external customers/clients/potential employees

Strong team working and collaborative skills

Ability to multi-task and work independently

Attention to detail

Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions

Strong analytical, problem solving and decision making skills

Demonstrated ability and experience in computer applications, use of electronic medical record keeping systems and MS Office


Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%):  Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%):  Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

Schedule Weekly Hours:


Caregiver Type:



First Shift (United States of America)

Is Exempt Position?


Job Family:


Scheduled Days of the Week:

As Scheduled (may include weekends and holidays)

Shift Start & End Time:

As Scheduled

Keywords: StCharles, North Las Vegas , RN Utilization Management, Other , North Las Vegas, Nevada

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