Utilization Review Nurse

Utilization Review Nurse (RN) - per diem role

Position Summary

The Utilization Review Nurse is responsible for coordinating and performing utilization management (UM) activities to ensure appropriate resource use, regulatory compliance, and high-quality patient care. This role partners closely with physicians, interdisciplinary teams, and external stakeholders to support efficient care delivery, minimize delays, and optimize patient outcomes.

Major Responsibilities

• Conducts and documents utilization review activities in accordance with department and medical center standards, ensuring timely and accurate concurrent and retrospective reviews using established criteria.
• Collaborates effectively with the healthcare team, including medical staff, hospital departments, and ancillary services, to expedite care delivery and avoid delays.
• Participates in multidisciplinary teams to support care coordination, implement utilization management strategies, and report key activities.
• Partners with managers, physicians, medical directors, and treatment teams to address patient care issues and align with best practices.
• Refers cases to Physician Advisors as needed to ensure accurate patient status determination and compliance with regulatory guidelines.
• Maintains knowledge of healthcare regulations, reimbursement practices, and factors impacting length of stay and resource utilization.
• Communicates clinical updates to payers and external review organizations, manages denial activity, and identifies and resolves avoidable delays.
• Develops and sustains strong relationships with community agencies and external partners to support patient and family needs.
• Serves as a subject matter expert and educator for staff on utilization management, admission status, and regulatory requirements.
• Delivers age-appropriate care, demonstrating understanding of growth and development across the lifespan and applying this knowledge to patient assessment and care planning.

Licensure, Registration, and/or Certification Required

• Active Registered Nurse (RN) license in the state of Wisconsin

Education Required

• Bachelor’s Degree in Nursing (BSN)

Experience Required

• Typically requires 3 years of experience in clinical nursing, utilization review, and/or quality management

Schedule:

Zero assigned

staffing to fill PTO/LOA, etc. Dept runs day shift, 7 days/week.

with a strong preference for availability 8-hours Saturday

Minimum of 8 hours a month -

One Holiday a year rotating each year

Department is closed Thanksgiving and Christmas

Knowledge, Skills & Abilities

• Proficiency in Microsoft Office (Excel, Outlook, PowerPoint, Word) or similar tools
• Strong understanding of utilization review criteria and acute care patient needs
• Demonstrated competency in InterRater Reliability (IRR) with a score of 80% or higher
• Critical thinking skills to evaluate clinical scenarios and apply medical necessity criteria
• Excellent communication and interpersonal skills with the ability to collaborate with patients, families, physicians, and payers
• Conflict resolution skills with a focus on achieving positive, collaborative outcomes
• Ability to build and maintain strong professional relationships across disciplines
• Commitment to ongoing professional development and active participation in organizational initiatives

Why Join Us

• Collaborative team environment committed to high-quality patient care
• Opportunity to influence patient outcomes and care delivery efficiency
• Professional growth within a leading healthcare organization