Inpatient Utilization Review RN - 1.0FTE

Summary: 

OMC Core Behavior Standards: 

Create Teamwork● Lead with Honesty & Integrity● Convey Compassion● Show Respect● Pursue Quality

Osceola Medical Center is committed to implementing these behavior standards as a foundation for how we hire, develop, and retain our team members. By intentionally selecting candidates whose values and behaviors align with these standards, we ensure that our mission is lived out every day, creating an environment where patients feel valued, respected, and confident that OMC is the place for all their healthcare needs.

Tentative Schedule:

Monday-Friday, Days: 8am-4:30pm 

Job Summary:

The Inpatient Utilization Review RN is a key member of the healthcare team responsible for ensuring the appropriate utilization of hospital resources through concurrent review, medical necessity evaluation, payer communication, and regulatory compliance activities. This role collaborates with physicians, nursing staff, case management, and third-party payers to support optimal patient outcomes while ensuring appropriate admission status, level of care, and reimbursement.

The Inpatient Utilization Review RN also assists with care coordination and discharge planning activities to support efficient patient progression throughout the continuum of care.

Responsibilities include:

Utilization Review and Medical Necessity Determination

• Perform concurrent reviews of inpatient, observation, swing bed, and other applicable patient stays to evaluate medical necessity and appropriate level of care.
• Apply established criteria to support admission status and continued stay determinations.
• Collaborate with providers to obtain documentation necessary to support medical necessity and reimbursement.
• Identify opportunities to improve documentation and ensure accurate patient status designation.
• Monitor length of stay and identify barriers to timely progression of care.

Payer Authorization and Denial Management

• Obtain and maintain required payer authorizations for admissions, continued stays, procedures, and post-acute services.
• Serve as liaison between the hospital, physicians, and insurance providers regarding utilization review activities.
• Assist in the appeal process for denied services and work collaboratively with interdisciplinary teams to reduce avoidable denials.
• Maintain current knowledge of payer requirements and reimbursement regulations.

Care Coordination and Discharge Planning

• Collaborate with patients, families, providers, nursing staff, and community resources to facilitate safe and effective transitions of care.
• Assist with discharge planning activities including referrals to post-acute services, home health agencies, rehabilitation facilities, and durable medical equipment providers.
• Identify barriers to discharge and coordinate interventions to support timely patient transitions.

Patient and Family Education

• Educate patients and families regarding care transitions, insurance requirements, available resources, and post-discharge services.
• Promote patient understanding and engagement in discharge and follow-up plans.

Documentation and Regulatory Compliance

• Maintain complete, accurate, and timely documentation in the electronic health record.
• Ensure compliance with CMS Conditions of Participation, Critical Access Hospital regulations, payer requirements, and organizational policies.
• Participate in audits, quality improvement initiatives, and regulatory reviews as needed.
• Track and report utilization review metrics, trends, and opportunities for improvement.

Knowledge, Skills, and Abilities

• Strong knowledge of utilization review principles, medical necessity criteria, reimbursement methodologies, and regulatory requirements.
• Understanding of CMS, Medicare, Medicaid, and commercial payer guidelines.
• Proficiency with electronic health records and Microsoft Office applications.
• Strong critical thinking, clinical judgment, and analytical skills.
• Excellent communication, negotiation, and collaboration abilities.
• Ability to work independently while managing multiple priorities and deadlines.
• Knowledge of discharge planning and care coordination processes.

Physical Requirements for the Role: 

• Sitting and standing associated with a normal office environment
• Some bending, stooping, and stretching
• Able to use office equipment such as copier, computer, telephone and fax machine
• Able to lift 5-10 lbs frequently, 20 lbs occasionally.
• Hand dexterity for office machine operation, mobility to complete errands, or sitting for extended periods of time
• Adequate vision, hearing and speaking abilities to perform essential duties, including telephone communication
• Able to prioritize activities when faced with competing demands

Qualifications:

• Graduate of an accredited nursing program. 
• Current Wisconsin Registered Nurse (RN) license required. 
• Bachelor’s degree in nursing (BSN) preferred. 
• Minimum of three (3) years of clinical nursing experience in acute care required. 
• Previous experience in utilization review, case management, care coordination, revenue cycle, or discharge planning preferred. 
• Experience working with Medicare, Medicaid, and commercial insurance plans preferred. 
• Familiarity with Critical Access Hospital regulations required. 
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or utilization review certification preferred.
• 3 years acute care experience

Work Environment: 

The Inpatient Utilization Review RN functions in a collaborative clinical and administrative environment requiring frequent interaction with providers, nursing staff, patients, families, payers, and community agencies. Work involves detailed chart review, documentation analysis, payer communication, and interdisciplinary care coordination. The role may require flexible scheduling to meet organizational and patient care needs.

Why Join OMC?

At OMC, we don’t just hire for skills—we hire for behaviors that align with our mission. We invest in team members who are committed to making a meaningful difference in the lives of our patients and in the communities we serve.