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Registered Nurse – Utilization Review
CoxHealthRegistered Nurse conducting utilization reviews for CoxHealth, a Missouri healthcare system. Evaluating medical necessity, level of care, and inpatient or observation services.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in patient care coordination, utilizing evidence-based practices and medical guidelines to ensure high-quality, cost-effective healthcare delivery. Proficient in conducting medical record reviews and communicating effectively with interdisciplinary teams and payers.
Highest-signal resume keywords
RN License Active In MissouriInterQual Level Of Care Criteria KnowledgeMilliman Care Guidelines KnowledgeCertified Case ManagerHospital Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Patient Care CoordinationMedical Record ReviewEvidence-Based CareResource UtilizationInpatient Services Appropriateness Determination
Soft Skills
Interpersonal SkillsVerbal CommunicationWritten CommunicationEmpathyProfessional Interaction
Tools & Technologies
Computer Skills
Certifications & Qualifications
RN LicenseCertified Case Manager
Industry Keywords
Acute Care IndicatorsNational Coverage DeterminationsLocal Coverage DeterminationsHospital Admission Criteria
About the role
Key responsibilities & impact- Collaborate with physicians and the multidisciplinary team to facilitate progression of care
- Monitor patient progress and intervene appropriately to ensure patient-focused, high-quality, evidence-based, appropriate, efficient, and cost-effective care
- Conduct concurrent medical record reviews for medical necessity and level of care using nationally recognized acute care indicators and criteria
- Prospectively or concurrently determine the appropriateness of inpatient or observation services based on medical documentation, medical guidelines, and insurance benefits
- Communicate information to payers in accordance with contractual obligations
- Serve as a resource to physicians
- Educate and provide information on resource utilization, national and local coverage determinations, and hospital admission criteria
Requirements
What you’ll need- Graduate of an accredited school of nursing
- Minimum of 3 years of hospital experience
- Excellent interpersonal skills, including the ability to be genuine and empathetic
- Excellent verbal and written communication skills with attention to detail
- Computer skills
- Ability to interact professionally and contribute to the interdisciplinary team
- Current RN license active in the state of Missouri
- Knowledge of InterQual Level of Care Criteria and/or Milliman Care Guidelines preferred
- Knowledge of local and national coverage determinations preferred
- Bachelor's of Nursing preferred
- Certified Case Manager preferred
Benefits
Comp & perks- Medical insurance
- Vision insurance
- Dental insurance
- Retirement plan with employer match
- Benefits available for employees working 20+ hours per week
- Workplace recognized by Modern Healthcare, Newsweek, Forbes, and Healthcare Innovation