The Staff Pad is proud to partner with St. Peter’s Health in Helena, Montana, in the search for a qualified and detail-oriented Utilization Management Nurse. This is an impactful opportunity to join a respected healthcare organization focused on delivering efficient, compliant, and cost-effective care.
Position Overview:
As a Utilization Management Nurse, you will support the Utilization Review RN Coordinator by overseeing and managing utilization functions across the organization. Your role is essential in ensuring that patients receive medically appropriate care while maintaining documentation integrity and reimbursement accuracy. You will act as a liaison among insurance providers, healthcare teams, and hospital departments, advocating for both patient needs and institutional best practices.
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Key Responsibilities:
Monitor patient care from ED admission through discharge to ensure compliance with utilization guidelines
Investigate, respond to, and resolve insurance denials and appeals
Collaborate with healthcare teams to confirm admission status, diagnosis, and treatment plan milestones
Conduct medical record reviews for prior authorization, medical necessity, and level of care determination using InterQual or MCG guidelines
Communicate directly with providers to obtain necessary clinical documentation
Track appeal submissions and outcomes; coordinate peer-to-peer reviews with insurance providers
Educate staff on utilization trends, policy changes, and process improvements
Maintain accurate documentation of all utilization and authorization activities
Promote adherence to quality standards and regulatory compliance
Qualifications:
Experience: Minimum 3 years in acute care; background in utilization management or healthcare insurance required
Education: LPN or RN; clinical preparation essential
Licensure: Current nursing license in the State of Montana
Preferred Certifications: Case Management and/or Utilization Review certification
Technical Skills: Proficiency in Word, Excel, and Meditech preferred
Ideal Candidate Traits:
Excellent interpersonal, communication, and negotiation skills
Strong organizational abilities and independent work ethic
Up-to-date knowledge of payer policies, regulatory guidelines, and best practices in utilization management
Compassionate, collaborative, and solutions-driven in navigating complex care coordination
St. Peter’s Health – Helena, Montana
Contribute to patient-centered care in a vibrant, community-focused hospital located in Montana’s scenic capital city.
PandoLogic.Keywords:Utilization Review Coordinator, Location:Helena,MT-59604, PL:597754259