Utilization Review RN

Job Summary and Responsibilities

As our Utilization Review RN, you will play a critical role in helping patients receive appropriate and necessary medical care by ensuring the accuracy of admission status, validating the necessity of continued hospitalization, and navigating intricate payer requirements. This dedication will empower our medical staff to focus on clinical care, prevent unnecessary financial burden for both patients and the organization, and ultimately facilitate a smooth and compliant healthcare journey for every individual we serve.

Every day you will meticulously review medical records against established utilization review guidelines and critical thinking principles to determine appropriate admission and continued stay status. You will be expected to collaborate extensively with a diverse range of stakeholders including attending physicians, consultants, Care Coordination staff, and external payers to secure necessary authorizations and prevent denials. This includes proactively identifying and addressing deficiencies in patient status orders, facilitating communication with insurance providers, coordinating peer-to-peer discussions when required, and ensuring documentation of a working DRG for each assigned patient.

To be successful in this role, you will possess exceptional critical thinking and analytical reasoning skills to accurately interpret complex medical records and apply utilization review criteria. You will also need strong communication, negotiation, and interpersonal abilities to effectively collaborate with physicians, care coordinators, and external payers, often in challenging situations. Furthermore, a comprehensive understanding of utilization review principles, hospital policies, and external regulatory requirements (such as PRO and Joint Commission standards) is essential to ensure compliance and drive positive outcomes.

• Ensures timely communication and follow up with 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.
• Communicates the need for proper notifications and education in alignment with status changes.
• Engages with Denials RN or Revenue cycle vendor to identify priorities on concurrent denials based on payer timeframes.
• Establishes and documents a working DRG on each assigned patient at the time of initial review as directed.

Job Requirements

Required

• Active Registered Nurse license in the State of California
• Graduate of an accredited school of nursing
• Minimum two (2) years of acute hospital clinical experience OR Masters degree in Case Management or Nursing field in lieu of 1 year experience

Preferred

• Bachelor's Degree in Nursing (BSN) or related healthcare field
• Five (5) years of nursing experience
• Certified Case Manager (CCM) or Accredited Case Manager (ACM)

Where You’ll Work

Founded in 1989, Dignity Health at Mercy Hospital of Folsom is a 106-bed, acute care, nonprofit hospital located in Folsom, California. Serving over 60,000 patients annually, the hospital offers a full complement of services including heart care, cancer care, women’s health, and neurology. Additionally, Mercy Hospital of Folsom has been recognized as an LGBTQ+ Healthcare Equality Leader by the Human Rights Campaign Foundation. It is a Joint Commission-certified Primary Stroke Center, and has been awarded the AMA/ASA’s Get the Guidelines - Stroke Gold Plus Quality Achievement, recognizing the hospital’s commitment to providing the best stroke care. It was recently named a Leapfrog 2025 Top General Hospital.

One Community. One Mission. One California