Utilization Review RN

Mandatory Compliance & Housing Guidelines

• Compliance Deadline: Full compliance is strictly required 2 weeks prior to the start date.
• Licensure Flexibility: Active, unrestricted RN license from any US state, Commonwealth of Puerto Rico, or US territory is accepted (an Arizona state license is not required).
• Housing Rules: Shared contractor housing only. Hospital rental property is limited and subject to availability. No pets or family allowed per hospital policy.

Position Summary

The Utilization Review (UR) Nurse serves as a key liaison between clinical care, finance, and regulatory compliance. This role verifies medical necessity, monitors patient care needs, ensures proper clinical documentation for reimbursement, and works to reduce length of stay and avoid care delays. The UR Nurse manages resource utilization, prevents payer denials, and ensures adherence to CMS and Joint Commission standards to support organizational efficiency and patient outcomes.

Key Responsibilities

• Utilization & Care Review: Verify medical necessity, confirm correct patient status, and monitor ongoing service needs to reduce unnecessary length of stay.
• Discharge & Care Transitions: Coordinate with providers and interdisciplinary teams on resource management, discharge planning, and seamless care transitions.
• Revenue Cycle & Documentation Support: Review and support accurate clinical documentation to ensure appropriate reimbursement and communicate with payers to prevent coverage denials.
• Regulatory Compliance: Ensure all utilization practices align with CMS, Joint Commission, and organizational standards.
• Quality Improvement: Participate in clinical reporting, auditing, and quality improvement initiatives.

Qualifications & Requirements

• Education: Bachelor’s Degree in Nursing (BSN) required.
• Licensure: Active, full, and unrestricted RN license in any US state, territory, or Puerto Rico.
• Certifications: Current American Heart Association (AHA) Basic Life Support (BLS) required throughout employment.
• Experience:
  • Minimum 3 years of clinical nursing experience in direct patient care.
  • At least 2 years in an inpatient setting (Med/Surg, PACU, ICU, Step-Down, Telemetry, etc.) or direct-care home health setting.
  • Demonstrated knowledge of Utilization Review, Case Management, and Purchased Referred Care (PRC) processes.
  • Proficiency with Electronic Health Record (EHR) systems.

About the Organization & Community

Tuba City Regional Health Care Corporation is a 73-bed, Joint Commission-accredited regional referral center providing inpatient, outpatient, emergency, surgical, and specialty services across a 4,400-square-mile service area on the Navajo, Hopi, and Southern Paiute Reservations. Located on the Colorado Plateau in northwestern Arizona, Tuba City offers a culturally rich, diverse community and a dynamic healthcare environment.