Staff Nurse - Utilization Review

Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.

Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.

SUMMARY:

We are currently seeking a Staff Nurse to join our Utilization Management department for the Emergency Department

This position is a 0.8 FTE (8 shifts/ pay period), 8-hour shifts, Evenings (4:30 pm-1 am), with up to Every Other Weekend rotation. Note: Note: Current weekend assignment is typically every 2-3 weeks however is subject to change based on staffing needs and may require up to Every Other Weekend coverage.

SPECIFIC RESPONSIBILITIES:

The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. The RN conducts timely reviews of inpatient and outpatient medical records to determine the appropriateness of admissions, continued stays, and the level of care using established criteria and guidelines (e.g., InterQual, MCG). This role collaborates with healthcare providers, patients, payers, and internal departments to ensure quality care while optimizing resource utilization and controlling costs.

Assessment:

• Collects, reviews, and documents clinical data relevant to utilization management, including patient status, treatment plans, and healthcare utilization. Applies nationally recognized criteria (e.g., InterQual, MCG) to assess the appropriateness of services

Outcomes Identification:

• Identifies expected outcomes related to care transitions, resource use, and reimbursement to optimize patient health outcomes and reduce unnecessary utilization

Planning:

• Develops a utilization management plan by coordinating with clinical teams, payers, and discharge planners to support timely care progression and appropriate resource use

Implementation:

• Implements review processes to evaluate necessity and efficiency of services. Initiates communication with physicians and payers to resolve authorization issues and prevent delays in care

Evaluation:

• Continuously evaluates the appropriateness of hospital admissions, continued stays, and treatment plans in accordance with payer guidelines and evidence-based practice

Quality of Practice:

• Promotes quality through evidence-based utilization review processes and actively contributes to performance improvement initiatives

Education:

• Attains and maintains current knowledge in UR/UM practices, payer requirements, clinical guidelines, and regulations affecting utilization management

Professional Practice:

• Evaluates personal practice against professional standards, licensing requirements, and Hennepin Healthcare policies.

Collegiality:

• Collaborates with nursing, providers, case management, finance, and payer representatives. Contributes to professional development by sharing knowledge and supporting team education

Collaboration:

• Utilizes principles of relationship-based care to collaborate with care teams, patients, families, and external entities to facilitate effective care coordination and appropriate resource utilization

Ethics:

• Applies ethical decision-making when handling authorization issues, appeals, and coverage decisions. Advocates for patient needs while balancing organizational goals and payer requirements

Evidence-Based Nursing Practice and Nursing Research:

• Applies evidence-based criteria for utilization review decisions. Supports data collection and reporting to enhance outcomes

Resource Utilization:

• Considers safety, effectiveness, cost, and legal compliance when recommending levels of care or authorizations. Ensures documentation supports accurate coding, billing, and compliance.

Leadership:

• Demonstrates leadership through decision-making, communication with multidisciplinary teams, and proactive problem-solving related to authorization and utilization challenges

Self-Evaluation:

• Reviews and reflects on own practice related to guidelines, regulations, and departmental goals.

Safe Practice:

• Participates in maintaining a safe, efficient, and regulatory-compliant work environment; adheres to Hennepin Healthcare’s protocols and confidentiality standards

Provide Education and Mentorship:

• Demonstrates knowledge and application of adult learning needs and principles. Understands, articulates, and promotes the HHS Nursing Vision and Practice Model in relation to skill set

QUALIFICATIONS:

Minimum Qualifications:

• 1 year of recent utilization review, utilization management or care coordination nursing experience
• 1 year of recent professional Emergency Department nursing (RN) experience

Preferred Qualifications:

• Bachelor’s degree in nursing

• Certification in area of clinical specialty

• Minimum 2 years of recent clinical experience (e.g., med/surg, ICU, ED, or case management)

• Strong understanding of utilization review/utilization management principles

• Familiarity with InterQual, MCG, or similar clinical decision-making tools

• Excellent critical thinking, communication, and documentation skills

• Proficiency with EMRs and healthcare documentation systems

• BSN Preferred. Bachelor of Nursing degree is strongly encouraged. Advancement in academic education will be discussed as part of individual professional development during the annual performance review

License/Certifications:

• Possession of a valid license as a Registered Nurse issued by the State of Minnesota.

You've made the right choice in considering Hennepin Healthcare for your employment. We offer a wealth of opportunities for individuals who want to make an impact in our patients' lives. We are dedicated to providing Equal Employment Opportunities to both current and prospective employees. We are driven to connect talented individuals with life-changing career opportunities, enabling you to provide exceptional care without exception. Thank you for considering Hennepin Healthcare as a future employer.

Please Note: Offers of employment from Hennepin Healthcare are conditional and contingent upon successful clearance of all background checks and pre-employment requirements.

• We offer a competitive pay rate based on your skills, licensure/certifications, education, experience related to this position, and internal equity.
• We provide an extensive benefits program that includes Medical; Dental; Vision; Life, Short and Long-term Term Disability Insurance; Retirement Funds; Paid Time Off; Tuition reimbursement; and license and Certification reimbursement (Available ONLY for benefit eligible positions).
• For a complete list of our benefits, please visit our career site on why you should work for us.