University of Mississippi Medical Center
RN - Utilization Reviewer - Coordinated Care
University of Mississippi Medical Center, Jackson, Mississippi, United States, 39200
Job Title
RN - Utilization Reviewer - Coordinated Care
Job Summary Accountable to perform utilization management services for a designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the UM process to the appropriate manager and performs job duties in accordance with the medical center's purpose.
Education & Experience
Four (4) years RN experience, including one (1) year in performance improvement, utilization review, or case management.
Certifications, Licenses or Registration Required
Valid RN license.
CPUM (Certified Professional in Utilization Management), ACM (Accredited Case Manager), or CCM (Certified Case Manager) preferred.
Knowledge, Skills & Abilities
Knowledge of the aspects of utilization review.
Excellent interpersonal verbal and written communication and negotiation skills.
Skills in the use of personal computers and related software applications.
Ability to gather data, compile information, and prepare reports.
Ability to identify process improvements.
Good working knowledge of medical procedures and diagnoses, procedure codes (ICD‑10, CPT, DSM‑IV).
Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families.
Demonstrate commitment to the Organization’s mission and behavioral expectations.
Ability to use medical necessity guidelines with minimal supervision.
Equipped to work remotely with high‑speed internet via cable and Windows 10.
Responsibilities
Performs all aspects of prospective, concurrent, retrospective and denial reviews for individual cases, including benefit coverage issues, medical necessity, appropriate level of care, and mandated services.
Assists in the collection and reporting of financial indicators such as case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals; uses data to drive decisions and plan/implement performance improvement strategies.
Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team.
Applies approved clinical appropriateness criteria to monitor admissions and continued stays, identifies at‑risk populations, and refers cases as needed.
Communicates with third–party payers to facilitate covered day reimbursement certification and resolves payer issues.
Works collaboratively with physicians, nursing and other members of the interdisciplinary team to ensure timely, appropriate patient management.
Ensures safe care to patients adhering to policies, procedures, and standards, while managing time, supply, productivity, and accuracy.
Promotes professional growth by meeting mandatory/continuing education requirements and serving as a preceptor/mentor.
Participates in clinical performance improvement activities.
Accepts that duties may change; management retains the right to add or change responsibilities at any time.
Environmental And Physical Demands
Occasional exposure to high noise level and heat/cold; no handling of potentially dangerous equipment.
Occasional working hours beyond regularly scheduled hours; occasional travelling to off‑site locations.
Occasional work subject to significant volume changes; occasional bending, lifting up to 25 pounds, reaching, kneeling, pushing/pulling, twisting, walking, cloning, seating, and standing.
Requires continual training to meet quality, safety, and cost‑efficiency goals.
Time Type Part time
FLSA Designation/Job Exempt No
Pay Class Hourly
FTE 100%
Job Posting Date 11/5/2025
Job Closing Date Open until filled if no date specified.
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Job Summary Accountable to perform utilization management services for a designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the UM process to the appropriate manager and performs job duties in accordance with the medical center's purpose.
Education & Experience
Four (4) years RN experience, including one (1) year in performance improvement, utilization review, or case management.
Certifications, Licenses or Registration Required
Valid RN license.
CPUM (Certified Professional in Utilization Management), ACM (Accredited Case Manager), or CCM (Certified Case Manager) preferred.
Knowledge, Skills & Abilities
Knowledge of the aspects of utilization review.
Excellent interpersonal verbal and written communication and negotiation skills.
Skills in the use of personal computers and related software applications.
Ability to gather data, compile information, and prepare reports.
Ability to identify process improvements.
Good working knowledge of medical procedures and diagnoses, procedure codes (ICD‑10, CPT, DSM‑IV).
Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families.
Demonstrate commitment to the Organization’s mission and behavioral expectations.
Ability to use medical necessity guidelines with minimal supervision.
Equipped to work remotely with high‑speed internet via cable and Windows 10.
Responsibilities
Performs all aspects of prospective, concurrent, retrospective and denial reviews for individual cases, including benefit coverage issues, medical necessity, appropriate level of care, and mandated services.
Assists in the collection and reporting of financial indicators such as case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals; uses data to drive decisions and plan/implement performance improvement strategies.
Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team.
Applies approved clinical appropriateness criteria to monitor admissions and continued stays, identifies at‑risk populations, and refers cases as needed.
Communicates with third–party payers to facilitate covered day reimbursement certification and resolves payer issues.
Works collaboratively with physicians, nursing and other members of the interdisciplinary team to ensure timely, appropriate patient management.
Ensures safe care to patients adhering to policies, procedures, and standards, while managing time, supply, productivity, and accuracy.
Promotes professional growth by meeting mandatory/continuing education requirements and serving as a preceptor/mentor.
Participates in clinical performance improvement activities.
Accepts that duties may change; management retains the right to add or change responsibilities at any time.
Environmental And Physical Demands
Occasional exposure to high noise level and heat/cold; no handling of potentially dangerous equipment.
Occasional working hours beyond regularly scheduled hours; occasional travelling to off‑site locations.
Occasional work subject to significant volume changes; occasional bending, lifting up to 25 pounds, reaching, kneeling, pushing/pulling, twisting, walking, cloning, seating, and standing.
Requires continual training to meet quality, safety, and cost‑efficiency goals.
Time Type Part time
FLSA Designation/Job Exempt No
Pay Class Hourly
FTE 100%
Job Posting Date 11/5/2025
Job Closing Date Open until filled if no date specified.
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