Why Choose Saint Joseph Health System

• At Saint Joseph Health System our values guide every decision we make. Even when challenges arise we remain committed to our mission: caring for every person who needs us. We invest in our people our technology and our capabilities so we can continue delivering exceptional compassionate care to our communities.

What We Offer

• Tuition reimbursement for all full-time and part-time colleagues starting on day one

• Comprehensive benefits beginning day one (Medical Dental Vision PTO Life Insurance STD/LTD and more)

• Retirement savings plan with employer match

• Generous paid time off program plus 7 paid holidays

• No mandatory overtime

• Employee referral incentive program

• Access to state-of-the-art equipment unlimited CEUs and a supportive team-focused work environment

What You Will Do

• Conduct clinical reviews of patient records to evaluate medical necessity appropriateness of admission treatment and length of stay across all payor types
• Apply standardized criteria regulatory guidelines and insurance requirements to support reimbursement and compliance
• Collaborate with physicians nursing staff and interdisciplinary teams to ensure appropriate resource utilization and care planning
• Review admissions and ongoing patient cases; recommend or escalate cases that do not meet criteria to leadership or the Utilization Review Committee
• Facilitate timely discharges transfers and recertifications when level of care is no longer appropriate
• Partner with Medicare Medicaid and private insurers to ensure accurate documentation and reimbursement processes
• Respond to denials and authorization changes by reviewing medical records and communicating outcomes to care teams and patients
• Identify trends and utilization concerns; contribute to performance improvement and quality initiatives
• Maintain accurate records compile reports and support utilization review program operations
• Provide education to clinical staff on documentation requirements coverage guidelines and utilization processes
• Support compliance with all regulatory accreditation and organizational standards
• Participate in committee meetings and assist in development of utilization review plans and processes

What You Will Need

• Graduate of an accredited Registered Nurse (RN) program; Bachelors Degree in Nursing preferred
• Active RN license (state-specific requirement applies)
• Minimum of 2 years of acute care nursing experience
• Prior utilization review case management or payer review experience preferred
• Strong knowledge of Medicare Medicaid and commercial insurance guidelines
• Solid understanding of clinical care practices diagnoses treatment modalities and hospital operations
• Excellent communication skills with the ability to collaborate effectively across teams
• Strong analytical and critical thinking skills to assess clinical appropriateness and compliance
• Proficiency in computer systems and Microsoft Office applications
• Ability to manage multiple priorities in a fast-paced healthcare environment
• Flexibility to adapt to changing schedules workflows and departmental needs