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Registered Nurse – Utilization Review, Per Diem
HonorHealthUtilization Review RN evaluating medical necessity and documentation for HonorHealth, an Arizona nonprofit healthcare system. Coordinating payer reviews, appeals, and hospital-level-of-care determinations.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and Case Management, with a strong focus on medical necessity evaluations and collaboration with healthcare teams to ensure quality patient care. Proficient in reviewing clinical documentation and navigating payer requirements to optimize service delivery.
Highest-signal resume keywords
Utilization Review (UR)Case ManagementRegistered Nurse (RN) LicensureMedical Necessity KnowledgeCollaboration with Healthcare Teams
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ReviewMedical Record ReviewHospital-Level Care DeterminationData ReportingQuality Outcome Measurement
Soft Skills
Effective CommunicationCollaborationProblem-Solving
Certifications & Qualifications
Certified Case Management (ACM)
Industry Keywords
MedicareAHCCCSSelf-PayAcute Care SettingDRG Classifications
About the role
Key responsibilities & impact- Review and monitor utilization of healthcare services to maintain high-quality, cost-effective care
- Conduct comprehensive medical-necessity reviews for extended stays, outpatient observation, inpatient stays, and ancillary services
- Coordinate and conduct reviews for Medicare, AHCCCS, self-pay, and other payers upon admission and concurrently throughout admission
- Review clinical documentation and facilitate modifications to accurately reflect level of service and severity of illness
- Perform initial and concurrent reviews for patients entering the healthcare continuum
- Facilitate delivery of services through effective utilization of available resources
- Perform medical record reviews as required by payers
- Interface with the Care Management team regarding quality outcome measurements
- Collaborate with physicians, case managers, payers, and others to appeal denials and trended issues
- Work with medical records, finance, and physician groups to improve documentation and data reporting
- Initiate chart reviews, conduct follow-up reviews, and round on patients to ensure continuity of utilization-review reviews
- Maintain systems identifying admissions by diagnosis, DRG classifications, and other categories
- Notify physicians and appropriate staff about documentation issues requiring clarification
- Determine qualifications for hospital-level care using established criteria
- Perform other duties as assigned
Requirements
What you’ll need- Associate's Degree in Nursing from an accredited NLN/CCNE institution - Required
- Bachelor's Degree in Nursing from an accredited NLN/CCNE institution - Preferred
- 1 year experience in UR/UM or Case Management - Required
- 3 years Registered Nurse experience in an acute care setting - Required
- Registered Nurse (RN) State and/or Compact State Licensure - Required
- Certified Case Management (ACM) Case Management Certification - Preferred
- Medical necessity and utilization review knowledge
- Ability to review clinical documentation and medical records
- Knowledge of Medicare, AHCCCS, self-pay, and other payer requirements
- Ability to determine hospital-level-of-care qualifications using set criteria
- Ability to collaborate with physicians, case managers, payers, and other stakeholders
- Day-shift availability, 7:30–4:00, with team operations Monday through Sunday
- Remote work after training
Benefits
Comp & perks- Remote work after training
- Day shift, 7:30–4:00
- PRN/per diem scheduling