Utilization Review RN

The Staff Pad is proud to partner with St. Peter’s Health in Helena, Montana, in the search for a qualified and detail-oriented Utilization Management Nurse. This is an impactful opportunity to join a respected healthcare organization focused on delivering efficient, compliant, and cost-effective care. Position Overview: As a Utilization Management Nurse, you will support the Utilization Review RN Coordinator by overseeing and managing utilization functions across the organization. Your role is essential in ensuring that patients receive medically appropriate care while maintaining documentation integrity and reimbursement accuracy. You will act as a liaison among insurance providers, healthcare teams, and hospital departments, advocating for both patient needs and institutional best practices. Key Responsibilities: Monitor patient care from ED admission through discharge to ensure compliance with utilization guidelines Investigate, respond to, and resolve insurance denials and appeals Collaborate with healthcare teams to confirm admission status, diagnosis, and treatment plan milestones Conduct medical record reviews for prior authorization, medical necessity, and level of care determination using InterQual or MCG guidelines Communicate directly with providers to obtain necessary clinical documentation Track appeal submissions and outcomes; coordinate peer-to-peer reviews with insurance providers Educate staff on utilization trends, policy changes, and process improvements Maintain accurate documentation of all utilization and authorization activities Promote adherence to quality standards and regulatory compliance Qualifications: Experience: Minimum 3 years in acute care; background in utilization management or healthcare insurance required Education: LPN or RN; clinical preparation essential Licensure: Current nursing license in the State of Montana Preferred Certifications: Case Management and/or Utilization Review certification Technical Skills: Proficiency in Word, Excel, and Meditech preferred Ideal Candidate Traits: Excellent interpersonal, communication, and negotiation skills Strong organizational abilities and independent work ethic Up-to-date knowledge of payer policies, regulatory guidelines, and best practices in utilization management Compassionate, collaborative, and solutions-driven in navigating complex care coordination