Top 22 Utilization review nurse Jobs in Gary, In

Utilization Review Nurse
St. Bernard Hospital —Chicago, IL
- $88,000 - $123,000 a year
- Full-time
- Background check
- Nursing
- RN License
- Free parking
- Health savings account
Quick Apply
23h
Utilization Management Registered Nurse (RN) - Remote
Guidehealth —Chicago, IL
- $70,000 - $75,000 a year
- Full-time
- Remote
- Microsoft Word
- Nursing
- Microsoft Excel
- Paid parental leave
- Disability insurance
Nurse Auditor - Medical Bill Review (Remote)
Rising Medical Solutions —Chicago, IL
- Full-time
- Hybrid work
- RN License
- Customer service
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
Medical Case Manager II
CorVel Corporation —Merrillville, IN
- $66,941 - $101,258 a year
- Full-time
- Remote
- Nursing
- RN License
- Computer literacy
- Health savings account
- Disability insurance
Quick Apply
10d
Nurse Care Manager
Evergreen Nephrology —Chicago, IL
- $90,000 - $103,000 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
- Paid parental leave
- Health savings account
Quick Apply
ED UTILIZATION REVIEW/CASE MANAGER
Insight —Chicago, IL
- $85,000 - $90,000 a year
- Acute care
- Microsoft Word
- Nursing
- Disability insurance
- Health insurance
Quick Apply
Nurse Manager
Edgewater Health —Gary, IN
- CPR Certification
- Nursing
- Clean driving record
Quick Apply
8d
Team Manager Home Care (RN)
VITAS Healthcare —Tinley Park, IL
- $95,000 - $110,000 a year
- Full-time
- Nursing
- RN License
- Mid-level
- Mileage reimbursement
- Disability insurance
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Inpatient Care Manager
Advocate Aurora Health —Chicago, IL
- $38.20 - $57.30 an hour
- Full-time
- Nursing
- RN License
- Hospital
Administrator Home Health
Elara Caring —Tinley Park, IL
- $120,000 - $140,000 a year
- Full-time
- Nursing
- RN License
- Office
- Mileage reimbursement
- Paid holidays
Quick Apply
Functional Health Nurse RN / Wellness Coach
Midwest Medical Weight Loss & Aesthetics —Orland Park, IL
- $30 - $40 an hour
- Full-time
- Nursing
- HIPAA
- Inpatient
- Health insurance
- Employee discount
Quick Apply
9d
Transfusion Safety Clinical Specialist
UChicago Medicine —Chicago, IL
- Full-time
- Nursing
- RN License
- 3 years
Transfer RN/UR
Insight —Chicago, IL
- $70,000 a year
- Full-time
- RN License
- Hospital
- Mid-level
- Disability insurance
- Health insurance
Quick Apply
ED Care Manager
Advocate Aurora Health —Oak Lawn, IL
- $38.20 - $57.30 an hour
- Full-time
- Nursing
- RN License
- Mid-level
5d
Home Health Registered Nurse (RN) (Per Diem) | Spanish Speaking | Maywood, Cicero, Berwyn
BEST HOME HEALTHCARE NETWORK —Tinley Park, IL
- $50,000 - $100,000 a year
- Weekends as needed
- Hybrid work
- Spanish
- Nursing
- Heavy lifting
Quick Apply

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Utilization Review Nurse

St. Bernard Hospital -
Chicago, IL

Quick Apply

Job Details

Full-time
$88,000 - $123,000 a year
23 hours ago

Benefits

Free parking
Health savings account
Health insurance
Dental insurance
Tuition reimbursement
Paid time off
Employee assistance program
Vision insurance
403(b)

Qualifications

Direct patient care
Nursing
Inpatient experience
Medicare
RN License
Managed care organization experience
Bachelor of Science
CMS
CMS regulatory compliance
Medicare regulations
Bachelor of Science in Nursing
Medicaid regulations
Medicaid
Acute care experience

Full Job Description

We are seeking a detail-oriented and knowledgeable Utilization Review Nurse to join our healthcare team. The ideal candidate will possess extensive clinical experience, including inpatient and outpatient settings, with a focus on utilization management, medical documentation review, and compliance with healthcare regulations. This role involves evaluating patient care plans to ensure appropriate utilization of resources while maintaining quality standards and regulatory adherence.

The Utilization Review RN is responsible for ensuring appropriate patient status determination, medical necessity review, regulatory compliance, payer authorization management, denial prevention, and revenue integrity. The Utilization Review RN collaborates with physicians, physician advisors, case managers, social workers, and payers to ensure patients receive care in the appropriate setting while optimizing reimbursement and maintaining compliance with CMS, Joint Commission, and payer requirements. The Utilization Review RN actively participates in throughput initiatives, length-of-stay management, observation reduction strategies, denial mitigation efforts, and clinical documentation improvement processes.

Required Education:

Graduate of an accredited School of Nursing.
Current unrestricted Illinois Registered Nurse (RN) license.
Bachelor of Science in Nursing (BSN) preferred; required within 2 years of hire if not currently obtained.
Current knowledge of CMS Conditions of Participation, Medicare regulations, and payer requirements.

Desirable Education:

Bachelor’s degree in Nursing

Required Experience:

Minimum two (2) years acute care clinical nursing experience
Minimum two (2) years Utilization Management, Utilization Review, Case Management, Revenue Cycle, or Care Coordination experience
Experience with InterQual and/or MCG (Milliman) criteria
Experience working with Medicare, Medicaid, Managed Medicare, Commercial, and Managed Care payers

Desirable Experience:

Minimum of three (3) years of Utilization Review experience in a health care setting.

Preferred Certifications:

Accredited Case Manager (ACM)
Certified Case Manager (CCM)
Certified Professional in Utilization Management (CPUM)
Certification in Healthcare Quality or Revenue Cycle

Duties & Responsibilities:

Perform admission review for inpatient stays and 23-Hour Observation utilizing InterQual Criteria and assigning an initial LOS, if case meets criteria.
Provide third party payers the necessary information to secure hospital reimbursement and timely transfer.
Collaborate with the physician advisor regarding all cases that do not meet criteria. Escalate cases that fail medical necessity criteria to the Physician Advisor for secondary review.
Collect and record medical and other data needed to document a current review.
Obtain patient information in order to assess the needs of the patient and ensure a safe, timely, and cost-effective discharge.
Identify potential quality issues and presents material to appropriate medical staff and/or advise Director of Clinical Case Management to send case information to the Utilization Review Committee for recommendation of action.
Identify areas of over or under utilization and referrals to the appropriate persons.
Assess patient needs based on age and individual development and shares information with the Discharge Planning Team.
Work with the Social Worker and attending physician to provide appropriate referrals for continuing care after hospitalization (i.e. home health services, durable medical equipment, and community support).
Identify needs for alternative care setting (i.e. nursing home, sub acute, psychiatric, intermediate care facility) to collaborate with the Social Worker to arrange placement in a timely manner.
Document all admissions and concurrent clinical information, as well as interventions, delays, and secondary review requests in EMR utilization record.
Document all communication with third party payers on the Utilization Review Communication Sheet to ensure professional staff and physicians are informed about potential issues for approval of hospital stay and restrictions on referral Utilization to ensure continuity of care.
Assist the Utilization Review Committee by collecting and compiling data.
Prepare and complete statistical and narrative reports.
Ensure compliance with the CMS Two-Midnight Rule.
Escalate cases that fail medical necessity criteria to the Physician Advisor for secondary review.
Facilitate peer-to-peer reviews when required by payers.
Monitor observation patients daily and identify opportunities for status conversion or discharge.
Authorization and Reimbursement Management

Pay: $88,000.00 - $123,000.00 per year

Benefits:

403(b)
Dental insurance
Employee assistance program
Free parking
Health insurance
Health savings account
Paid time off
Tuition reimbursement
Vision insurance

Work Location: In person

Quick Apply

Refine Your Search

utilization review nurse jobs in gary, in

Utilization Review Nurse

Utilization Management Registered Nurse (RN) - Remote

Nurse Auditor - Medical Bill Review (Remote)

Medical Case Manager II

Nurse Care Manager

ED UTILIZATION REVIEW/CASE MANAGER

Nurse Manager

Team Manager Home Care (RN)

Inpatient Care Manager

Administrator Home Health

Functional Health Nurse RN / Wellness Coach

Transfusion Safety Clinical Specialist

Transfer RN/UR

ED Care Manager

Home Health Registered Nurse (RN) (Per Diem) | Spanish Speaking | Maywood, Cicero, Berwyn

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