Job Description

The Utilization Review (UR) RN evaluates the medical necessity, appropriateness, and efficiency of healthcare services using MCG criteria, ensuring compliance with CMS regulations and payer requirements. This role facilitates timely insurance pre-authorizations, confirms medical necessity, and helps prevent avoidable denials. The UR RN works closely with clinical teams, case management, and payers to support safe, efficient care transitions and optimize reimbursement.

The UR RN also collaborates with the Revenue Cycle Director and finance teams to investigate denials, inappropriate admission order status, avoidable revenue loss, and other financial risks. Responsibilities include monitoring length of stay and avoidable days, and reporting trends and findings to the Utilization Review Committee to support regulatory compliance and continuous improvement in utilization practices.

Qualifications

What is required...

• Graduate of an accredited nursing program with a current Washington State Registered Nurse (RN) license or Multistate License (MSL) with Washington endorsement (maintenance required)
• Minimum of 3 years of clinical nursing experience in acute care
• Experience with evidence-based care guidelines such as InterQual or MCG
• Familiarity with CMS Conditions of Participation, commercial health insurance and managed care billing requirements

What is preferred...

• Bachelor of Science in Nursing (BSN)
• Experience working with Cerner EHR
• Knowledge of care guidelines from MCG
• Hospital case management experience

Additional Information

Wage: Wage range currently starts at $41.39/hour and goes up to $75.91/hour. Actual wage will be based on years' of applicable experience. Shift Differentials apply; Evenings (3p-11p) = $3.00/hour, Nights (11p - 7a) = $4.50/hour, Weekends = $3.50/hour. This position may also qualify for an additional 15% premium in lieu of benefits.

FTE: Per Diem

Benefits: This position is not benefits eligible

Union Status: This is a WSNA union covered position