Utilization Review Nurse (RN) - Care Management

Clinical excellence. Compassionate care. Every patient. Every day. Be part of a collaborative healthcare team where your expertise in utilization management helps ensure appropriate levels of care, supports positive patient outcomes, and contributes to the efficient delivery of healthcare services across our organization.

Location Maury Regional Medical Center 12224 Trotwood Avenue Columbia, TN 38401 Shift PRN, as needed Sunday – Saturday day-shift options Job Summary As a Utilization Review Nurse, you’ll review assigned patient medical records and apply clinical decision support criteria to determine medical necessity and the appropriateness of admissions and continued stays.

In this position, you will also provide timely and accurate clinical information to insurers in accordance with payer contracts and the hospital Utilization Management Plan. This role also manages denials concurrently by facilitating prompt denial responses, coordinating peer-to-peer discussions, and escalating cases through established dispute resolution processes to support optimal patient outcomes and reimbursement.

Responsibilities

Evaluate patient admissions and ongoing care to determine medical necessity and appropriate level of care. Monitor length of stay, resource utilization, and clinical documentation to support quality and cost-effective care. Partner with physicians, case managers, and payers to obtain authorizations and resolve utilization review issues.

Coordinate denial prevention, appeals, and peer-to-peer reviews to support reimbursement and patient access to care. Track and analyze utilization review outcomes, helping achieve departmental performance and compliance goals. Participate in process improvement activities and stay current on utilization management guidelines, regulations, and payer requirements.

Qualifications

Current Registered Nurse (RN) license in the state of Tennessee (Required) Bachelor’s degree in nursing (BSN) (Preferred) Previous experience in Utilization Review, Case Management, Care Coordination, or Managed Care (Preferred) Certified Case Manager (CCM), Accredited Case Manager (ACM), or Utilization Management certification (Preferred) W hy Maury Regional Health Join an award-winning health system committed to serving the healthcare needs of southern Middle Tennessee!

Benefit-eligible positions include: Comprehensive Medical, Dental, and Vision plans Employer-paid life insurance Retirement savings plan with employer-matching Paid Time Off (PTO) Educational Assistance, Tuition Reimbursement and Student Loan Forgiveness Career advancement navigation opportunities Adoption assistance services Financial planning programs Maury Regional Health is committed to the principles of Equal Employment Opportunity in all aspects of the employer/employee relationship.

Maury Regional Health grants equal employment opportunities to all qualified persons without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), national origins (including ancestry), genetic information, disability, age, military/national guard/veteran status, sexual orientation, gender identity, or gender expression, or other status protected by state or federal law.

Statements made by applicants for employment on this application form will be checked for accuracy. Maury Regional Health campuses are tobacco-free. All tobacco use is prohibited.