UTILIZATION REVIEW NURSE (RN) - UTILIZATION MANAGEMENT in Reno, NV at Saint Mary's Regional Medical Center

Date Posted: 9/17/2020

Job Snapshot

Job Description

Responsibilities Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admission including appropriate patient status and continued stay reviews. Communicates all medical necessity review outcomes and denials to case management staff and providers . Engage in denial management protocols including Peer to Peer with Physicians and Reconsideration reviews. Accurate and timely recording of data in the Authorization tool. Prioritizes patient reviews based on situational analysis. Directs physician and patient communication regarding non-coverage of benefits and continued stay denials. Engage in denial management protocols including Peer to Peer with Physicians and Reconsideration reviews.


  1. Two (2) years clinical experience as a Case Manager in an acute care, post-acute, or payer setting within the last 5[AP(1]  years.
  2. Utilization review and denial management experience required.
  3. Current state RN licensure required.
  4. Must be able to communicate in English (Speak, Write)
  5. Demonstrates: - excellent communication skills both verbal and written - ability to facilitate and collaborate with an interdisciplinary team - flexibility to manage multiple complex cases simultaneously - attention to detail and follow-up - critical thinking and problem-solving skills.
  6. Current BLS (AHA) certificate
  7. Case Management Certification (CCM) preferred.
  8. Current knowledge Clinical Criteria including Milliman are Guild lines and InterQual Guidelines for severity of illness if service
  9. Current knowledge of CMS guidelines for clinical review and conditions of Participation.
Employees must be in their current position for a minimum of six calendar months and not received any disciplinary action within the last six months to apply and be considered for a transfer.


We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics.  If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf


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