Utilization Review RN
Where You’ll Work Hello Humankindness Chandler, Arizona, has a stable suburban population with an economy anchored by many large financial, and high tech companies. Located southeast of Phoenix, Chandler is a skillfully developed community of friendly, diverse neighborhoods with expansive parks, great schools, convenient shopping, and excellent career opportunities. For more than 50 years, Dignity Health’s Chandler Regional Medical Center has focused on quality patient care and service to the community. As the longest established hospital in the southeast valley, Chandler Regional has provided care for the Chandler community since 1961. The hospital recently added a new five-story tower with 100 patient beds, increasing the acute-care bed count to 429. This expansion increased emergency and trauma services, as well as the surgical unit and intensive care offerings. The word “dignity” perfectly defines what our organization stands for: showing respect for all people by providing excellent care. At Chandler Regional, our employees are the heart and soul of our organization. They are the reason we are able to live out our healing ministry within the communities we serve. Our doctors, nurses and allied health professionals are a regular self-contained support system for each other. This unique working culture is one of the reasons why a career with us is so rewarding. Now is the perfect time to come grow your career with one of Arizona's Most Admired Companies. Look for us on Facebook and follow us on Twitter. Job Summary and Responsibilities As our Utilization Management Nurse, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision-making, regulatory compliance, and responsible resource utilization. Every day, you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria. To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow. Skills needed: Knowledge of federal, state and managed care rules and regulations including CMS and AHCCCS. Working knowledge with INTERQUAL or Milliman preferred. Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers. Responsibilities: Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. Collaborates with facility RN Care Coordinators to ensure progression of care. Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status. Job Requirements Required: Graduate of an accredited school of nursing Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience RN: AZ or Compact License Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used Preferred: Bachelor's Degree in Nursing (BSN) or related healthcare field At least five (5) years of nursing experience Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification