Employment Type: Part time Shift: Rotating Shift
Description
This is a remote, PRN position but will need onsite training in Mishawaka Indiana. Shift: Days - 8 hr shift LOCAL CANDIDATES ONLY!
What You Will Do
- Conduct clinical reviews of patient records to evaluate medical necessity, appropriateness of admission, treatment, and length of stay across all payor types
- Apply standardized criteria, regulatory guidelines, and insurance requirements to support reimbursement and compliance
- Collaborate with physicians, nursing staff, and interdisciplinary teams to ensure appropriate resource utilization and care planning
- Review admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review Committee
- Facilitate timely discharges, transfers, and recertifications when level of care is no longer appropriate
- Partner with Medicare, Medicaid, and private insurers to ensure accurate documentation and reimbursement processes
- Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
- Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
- Maintain accurate records, compile reports, and support utilization review program operations
- Provide education to clinical staff on documentation requirements, coverage guidelines, and utilization processes
- Support compliance with all regulatory, accreditation, and organizational standards
- Participate in committee meetings and assist in development of utilization review plans and processes
What You Will Need
- Graduate of an accredited Registered Nurse (RN) program; Bachelor's Degree in Nursing preferred
- Active RN license (state-specific requirement applies)
- Minimum of 2 years of acute care nursing experience
- Prior utilization review, case management, or payer review experience preferred
- Strong knowledge of Medicare, Medicaid, and commercial insurance guidelines
- Solid understanding of clinical care practices, diagnoses, treatment modalities, and hospital operations
- Excellent communication skills with the ability to collaborate effectively across teams
- Strong analytical and critical thinking skills to assess clinical appropriateness and compliance
- Proficiency in computer systems and Microsoft Office applications
- Ability to manage multiple priorities in a fast-paced healthcare environment
- Flexibility to adapt to changing schedules, workflows, and departmental needs