Surgery Partners

Job Details

Description

APPLICATION DEADLINE: 06/14/2025

Job Summary:

The Registered Nurse - Utilization Review oversees and coordinates utilization review functions. This role ensures efficient, high-quality, cost-effective care while meeting regulatory requirements, supporting and facilitating appropriate resource utilization. This position works closely with physicians, nurses, social workers, insurance companies, and other departments to optimize patient outcomes and length of stay.

Hours:

• 0.6 FTE - 24 Hours Per Week
• Day Shift

Essential Job Functions:

• The Case Manager conducts medical record reviews using specific indicators and criteria as approved by medical staff, The Joint Commission, CMS, and other state and federal agencies while ensuring physician and nurse documentation meet set standards
• Understand utilization review/case management rules and guidelines to ensure compliance
• The Case Manager educates members of the healthcare team on case management and managed care concepts and serves as the patient advocate and enhances a collaborative relationship with the healthcare team, physicians, patients and families to maximize the patient’s and family’s ability to make informed healthcare decisions
• This position reinforces/facilitates patient/family education, to enhance a positive discharge transition
• Investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery
• The RN Case Manager will assist PI RN with data gathering as needed to support regulatory reporting
• Works collaboratively with Social Workers to support meeting psycho-social needs of patients and families or care givers
• Serve as a resource and mentor for case management and UR staff, offering guidance on complex cases and review criteria
• Coordinate with providers, case managers, and payers to facilitate appropriate level-of-care determinations
• Perform concurrent and retrospective reviews as needed, using evidence-based guidelines and organizational protocols
• Assist in training new staff and developing ongoing education for the case management and UR team
• Participate in the development and implementation of policies and procedures to improve discharge planning and UR processes
• Identify and escalate issues related to delays in care, denial trends, or gaps in documentation
• Collaborate with leadership on quality improvement initiatives and data reporting
• Attend interdisciplinary rounds and relevant departmental meetings
• Assist with Inpatient PI/chart audits, medication audits, antibiotic audits, unit-specific tracking tools
• Support and facilitate initiatives enhancing patient satisfaction
• Perform other duties as assigned

Qualifications, Knowledge & Ability:

• Demonstrates eligibility for employment in the U.S.
• Current licensure as RN in the State of Wisconsin required
• Associate’s Degree in Nursing required.
• Bachelor’s degree preferred.
• Three (3) years of Utilization Review experience required
• BLS certification is required upon hire

Benefits:

• Comprehensive health, dental, and vision insurance
• Health Savings Account with an employer contribution
• Company paid life insurance
• Free meals
• PTO
• 401(k) retirement plan with 4% company match
• Tuition reimbursement
• Wellness reimbursement

Equal Opportunity Employer

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