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Utilization Review Nurse

Arizona General Hospital Mesa, Arizona
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The posted compensation range of $36.96 - $53.60 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

Requisition ID 2025-405150 Employment Type PRN Department Care Coordination Hours/Pay Period 0 Shift Day Weekly Schedule Varied including holiday/weekends: 10 hr shifts Remote Yes Category Case Management and Social Work

Responsibilities

Under the general direction of the Director of Care Management, performs criteria-based concurrent and retrospective utilization review to support and encourage the efficient and effective use of resources; promote quality patient care; assist with patient care management; comply with applicable standards and regulations and provide information and education to clinical care providers in order to achieve optimal clinical, financial, operational and patient satisfaction outcomes.

Skills needed:

Knowledge of federal, state and managed care rules and regulations including CMS and AHCCCS. Working knowledge with INTERQUAL or Milliman preferred. Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers.

Responsibilities:

  • Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking.  Reviews include admission, concurrent and post discharge for appropriate status determination.
  • Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
  • Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. 
  • Ensures timely communication and follow upwith physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
  • Collaborates with facility RN Care Coordinators to ensure progression of care.
  • Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.

Qualifications

Minimum:

  • Graduate of an accredited school of nursing
  • Minimum two (2) years of acute hospital clinical  experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience
  • RN: AZ or Compact License
  • Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used

Preferred:

  • Bachelor's Degree in Nursing (BSN) or related healthcare field 
  • At least five (5) years of nursing experience
  • Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification 
Overview
Dignity Health – Arizona General Hospital located in southeast Mesa on Elliot Rd and Ellsworth Rd is a fully-equipped hospital open 24-hours, 7 days a week, 365 days a year. The facility features an emergency room, capacity for 50 inpatient beds, an Intensive Care Unit, 14 emergency room beds, four operating or procedure rooms, a full onsite laboratory and radiology suite complete with 64 slice CT scan, x-ray, ultrasound capabilities and MRI.
The word “dignity” perfectly defines what our organization stands for: showing respect for all people by providing excellent care. At Arizona General Mesa, our employees are the heart and soul of our organization. They are the reason we are able to live out our healing ministry within the communities we serve. Our doctors, nurses and allied health professionals are a regular self-contained support system for each other. This unique working culture is one of the reasons why a career with us is so rewarding.
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Equal Opportunity

CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.

CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.