RN Utilization Review Specialist | Case Management | Nights

Summary

The RN Utilization Review Specialist is responsible for conducting prospective and concurrent medical record review to determine medical necessity and appropriate level of care in accordance with nationally recognized criteria, CMS regulations, payer contractual requirements, and organizational policy. This role focuses exclusively on utilization management functions including admission review, continued stay review, payer communication, denial prevention, and regulatory compliance. The Utilization Review Specialist serves as a clinical resource to physicians and interdisciplinary teams regarding level of care determinations, documentation requirements, and medical necessity standards to support appropriate reimbursement and optimal resource utilization.

Responsibilities

Performs admission and continued stay reviews using approved evidence-based criteria and CMS 2MN rule. This includes reviewing admitting orders, history and physical documentation, clinical progress notes, and transfer requests to determine appropriate inpatient or observation status. The Specialist monitors length of stay and identifies cases at risk for medical necessity denial. All determinations are documented accurately and timely in designated utilization management systems in accordance with departmental standards.

Ensures compliance with CMS Conditions of Participation, Medicare regulations, and payer-specific policies. This includes understanding and appropriately applying federal notification requirements such as the Hospital Issued Notice of Non-Coverage (HINN), Advanced Beneficiary Notice (ABN), Medicare Outpatient Observation Notice (MOON), Important Message from Medicare (IMM), and Condition Code 44 (CC44) when applicable. The Specialist ensures physician orders and status determinations align with regulatory requirements and remains current on reimbursement and compliance updates impacting acute care services.

Communicates clear, concise, and timely clinical information to third-party payers to secure initial and continued stay authorizations. This includes submitting required documentation, responding to payer inquiries, and tracking authorization status. When cases do not meet medical necessity criteria, the Specialist facilitates peer-to-peer discussions in collaboration with the Physician Advisor and supports denial prevention efforts. The role also includes assisting with appeals as needed, communicating discharge notifications to payers, and closing authorizations appropriately upon completion of services.

Serves as a clinical resource to physicians and interdisciplinary team members regarding medical necessity, documentation standards, and level-of-care determinations. The Specialist collaborates with the Physician Advisor to address cases not meeting criteria and participates in escalation processes as necessary. Education is provided to providers regarding documentation improvements to support medical necessity and reimbursement integrity, while maintaining professional and solution-focused communication.

Identifies and documents avoidable days or delays related to medical necessity or payer requirements and participates in performance improvement initiatives aimed at reducing denials and optimizing resource utilization. The role supports tracking and reporting of utilization metrics such as denials, peer-to-peer outcomes, length-of-stay variances, and observation-to-inpatient conversions. Participation in UR team meetings and committee work may be required to support continuous improvement efforts.

Other duties as assigned,

Credentials

Essential

• BASIC LIFE SUPPORT (BLS)
• REGISTERED NURSE (RN)

Education

Essential

• ASSOCIATE'S DEGREE

BLS (aha)

Join us at Yuma Regional Medical Center dba Onvida Health

A career at Onvida Health is more than just a job. It’s a place to have a long and rewarding career, making a difference in the lives of those in our shared community. When you join our team, you become an integral part of a thriving community committed to improving the health and well-being of everyone in southwestern Arizona.

At Onvida Health, we believe in progress with purpose. Our commitment to innovation is matched by our dedication to kindness and integrity. We take our values seriously because we know they lead to better outcomes for our patients and a better experience for all of us. We’re looking for people who approach each day with a sense of possibility, a drive to make things better, and a commitment to kindness. If that sounds like you, you’re our kind of people.

If you’re looking for a career where innovation meets compassion, where you can grow and contribute to building a healthier tomorrow, Onvida Health is the place for you.

Life in Yuma, Arizona Yuma, recognized by Guinness World Records as the Sunniest City on Earth, offers more than just sunshine. It’s a place where the great outdoors meets a welcoming, tight-knit community. Hike scenic trails, explore the Colorado River, or immerse yourself in local cultural festivals – all while embracing the beauty of this desert oasis. With easy access to larger cities and popular destinations, Yuma makes it easy to balance a fulfilling career with time for personal adventures and relaxation.

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https://www.yumachamber.org/

Physical Requirements and working conditions for this position will be provided to you up on interview. Job Details Career area Case Mgt/Social Work Position Type Full Time Date Posted 08/14/2026 Location Yuma, AZ 85364, United States Job ID 13761