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Utilization Review RN
1 month ago
Are you a Registered Nurse (RN) looking for your next career adventure? We invite you to join our Case Management team as Utilization Review Nurse
Kingman Regional Medical Center (KRMC) is located in beautiful northwest Arizona. Experience the magic of Kingman's stunning Arizona sunsets and thrive in an outdoor enthusiast's dream destination with picturesque mountain ranges, nearby lakes, vibrant parks, and plenty of outdoor activity. Kingman is an incredible community to live, work, and play
Position Purpose: The Utilization Review Nurse performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities. The UM Nurse has an emphasis on the review, analysis, monitoring, and operation of the patient medical care plans and works toward optimal clinical, financial, operational, and satisfaction outcomes.
Hours/Shift: Full Time/Days M-F 8:00a-4:30p
Benefits: We offer you an excellent total compensation package, including a competitive salary, comprehensive benefits, and growth opportunities. We invest in you
- Exceptional Colleagues
- Join us and you'll be a part of a culture where we support each other and celebrate what makes each of us a special person as we work together with integrity, compassion, teamwork, respect, and accountability
- Our leaders demonstrate their commitment by gathering feedback, supporting, and empowering team members to do their best work through regular leadership rounding
- Health and Well-Being
- Medical, Dental, Vision, Employer Paid HSA for HDHP participants, Robust Wellness and Employee Assistance Program, Employer Paid Group Life, Short & Long-Term Disability
- Generous Paid Leave Accruals and PTO Cash Out Opportunities
- 403b Retirement Plan with Employer Contributions
- Employee Recognition Programs, Employee Discounts, and Employee Referral Bonus Program
- Employee Identity Theft Protection
- On-site daycare exclusive to our employees’ children of all ages
- Career Growth and Development
- Tuition Reimbursement/Scholarships for full-time employees
- As a not-for-profit organization, our employees who have qualified student loans may be eligible for the Public Service Loan Forgiveness program
- So much more
Key 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.
Qualifications:
- Education: Graduate of an accredited nursing school.
- Licensure: Active Arizona or compact state RN license.
- Experience: Minimum 3 years clinical (preferably med-surg/critical care), plus 1 year of utilization review or 2 years in case management.
- Skills: Strong clinical knowledge, communication, problem-solving, and proficiency in standard office tools. Ability to work with diverse teams and recognize quality care issues.
Work Requirements: 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.
About Us:Kingman Regional Medical Center (KRMC) is the largest healthcare provider and the only remaining not-for-profit hospital in Mohave County, Arizona. As a 235-bed multi-campus healthcare system, our medical center includes more than 1,900 employees, 270 physicians/allied health professionals, and 150 volunteers. KRMC is recognized as an innovator in rural healthcare and a teaching hospital. We provide a full continuum of highly technical and specialized medical services to meet the healthcare needs of our community. Year after year the Leapfrog Group has awarded KRMC an "A" Grade for Patient Safety. We strive to provide a culture of safety, integrity, teamwork, accountability, respect, and appreciation through recognition, career growth, and employee celebrations throughout the year for all our staff. Kingman Regional Medical Center is a great place to work, come join our team
