Utilization Review RN

The Staff Pad is proud to partner with St. Peter’s Health in Helena, Montana, in the search for a qualified and detail-oriented Utilization Management Nurse. This is an impactful opportunity to join a respected healthcare organization focused on delivering efficient, compliant, and cost-effective care.

Key Responsibilities:

• Monitor patient care from ED admission through discharge to ensure compliance with utilization guidelines
  

• Investigate, respond to, and resolve insurance denials and appeals
  

• Collaborate with healthcare teams to confirm admission status, diagnosis, and treatment plan milestones
  

• Conduct medical record reviews for prior authorization, medical necessity, and level of care determination using InterQual or MCG guidelines
  

• Communicate directly with providers to obtain necessary clinical documentation
  

• Track appeal submissions and outcomes; coordinate peer-to-peer reviews with insurance providers
  

• Educate staff on utilization trends, policy changes, and process improvements
  

• Maintain accurate documentation of all utilization and authorization activities
  

• Promote adherence to quality standards and regulatory compliance
  

Qualifications:

• Experience: Minimum 3 years in acute care; background in utilization management or healthcare insurance required
  

• Education: LPN or RN; clinical preparation essential
  

• Licensure: Current nursing license in the State of Montana
  

• Preferred Certifications: Case Management and/or Utilization Review certification
  

• Technical Skills: Proficiency in Word, Excel, and Meditech preferred
  

Ideal Candidate Traits:

• Excellent interpersonal, communication, and negotiation skills
  

• Strong organizational abilities and independent work ethic
  

• Up-to-date knowledge of payer policies, regulatory guidelines, and best practices in utilization management
  

• Compassionate, collaborative, and solutions-driven in navigating complex care coordination