Utilization Review RN Part-Time (Remote in Arizona)

Key Responsibilities:

• Conducts medical necessity reviews for Medicare, Medicaid, self-pay, and other insured patients.
• Verifies physician orders per Medicare and payer guidelines and ensures documentation reflects patient acuity accurately.
• Coordinates with medical staff, Case Managers, and Insurance Specialists to facilitate clear communication with payers, ensuring timely, accurate information.
• Consults with the Physician Advisor for complex cases and engages in denial management.
• Documents utilization review activities in the MCG system, maintains complete records, and collaborates across teams for quality care.
• Educates staff on clinical guidelines, utilization review, and payer regulations.
• Assesses patient cases using nationally recognized criteria for admission and care level.
• Collaborates with physicians to determine inpatient vs. observation status and performs Code 44 when necessary.
• Identifies cases needing further intervention, considers appropriateness and quality, and communicates expected length of stay per Medicare guidelines.
• Supports Case Managers and educates staff on CMS guidelines and documentation needs.
• Protects patient rights, ensuring confidentiality and compliance with hospital policies.
• Participates in committees and ongoing education, staying current with performance improvement and regulatory standards. 

Qualifications: 

• Residency: Must reside in Arizona to be eligible for remote work
• Education: Graduate of an accredited nursing school
• Licensure: Active Arizona or compact state RN license
• Experience:  Must have 1+ yrs of Utilization Review experience, preferably in both clinical and managed care, and 3 years clinical experience (preferably med-surg/critical care)
• Skills: Strong clinical knowledge, communication, problem-solving, and proficiency in standard office tools. Ability to work with diverse teams and recognize quality care issues

Work Requirements: Excellent verbal and written communication, interpersonal skills, and ability to use standard office equipment/software. Strong clinical skills and able to recognize quality issues, and knowledge of nationally recognized criteria used to make medical necessity determinations. Effective problem solving, analyzing complex situations, draw conclusions and implement appropriate actions efficiently. Ability to sit for 3-5 hours per day, stand 3-5 hours, and walk 3-5 hours.

About Us: Kingman Regional Medical Center (KRMC) is the largest healthcare provider and the only remaining not-for-profit hospital in Mohave County, Arizona. As a 235-bed multi-campus healthcare system, our medical center includes more than 1,900 employees, 270 physicians/allied health professionals, and 150 volunteers. KRMC is recognized as an innovator in rural healthcare and a teaching hospital. We provide a full continuum of highly technical and specialized medical services to meet the healthcare needs of our community. Year after year the Leapfrog Group has awarded KRMC an "A" Grade for Patient Safety. We strive to provide a culture of safety, integrity, teamwork, accountability, respect, and appreciation through recognition, career growth, and employee celebrations throughout the year for all our staff. Kingman Regional Medical Center is a great place to work, come join our team!