Utilization Review Nurse (RN) - Full-Time, Hybrid
Holy Cross

Employment Type:Full timeShift:Day Shift

Description:The Utilization Review Nurse is responsible for ensuring appropriate admission status and level of care for hospitalized patients in accordance with MCG/InterQual (Indicia) criteria, CMS regulations, and Managed Care payer requirements. This role partners closely with physicians, physician advisors, case management, and payers to support timely authorizations, concurrent reviews, and discharge planning while minimizing avoidable days and ensuring regulatory compliance.

• Full-time position
• Hybrid model (combination of on-site and remote work based on department needs)
• Ability to adapt to multiple UR roles including Observation, Inpatient Review, and Department Coordination
• Conduct initial and concurrent chart reviews to confirm admission and continued stay meet level-of-care criteria
  
• Provide telephonic or electronic clinical reviews to external payers to support authorization decisions
  
• Experience in Utilization Review, Case Management, or Managed Care
  
• Working knowledge of MCG/InterQual (Indicia) criteria
  
• Familiarity with CMS, Medicare, Medicaid, and commercial payer regulations
  
• Proficiency with Epic or similar EMR systems
  
• Strong clinical judgment, communication, and documentation skills
  

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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