Registered Nurse - Utilization Review at Trinity Health (Remote) · RemoteRN

Job description

Full time

Rotating Shift

This is a remote position but will need onsite training in Mishawaka Indiana. Shift: Days - 8 hr shift LOCAL CANDIDATES ONLY!

At Saint Joseph Health System, our values guide every decision we make. Even when challenges arise, we remain committed to our mission: caring for every person who needs us. We invest in our people, our technology, and our capabilities so we can continue delivering exceptional, compassionate care to our communities.

Tuition reimbursement for all full-time and part-time colleagues starting on day one
Comprehensive benefits beginning day one (Medical, Dental, Vision, PTO, Life Insurance, STD/LTD, and more)
Retirement savings plan with employer match
Generous paid time off program plus 7 paid holidays
No mandatory overtime
Employee referral incentive program
Access to state-of-the-art equipment, unlimited CEUs, and a supportive team-focused work environment

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

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

Registered Nurse - Utilization Review