Utilization review nurse-Ed (Tr/Prn) nights
Riverside Healthcare·Kankakee, Illinois
Riverside Healthcare·Kankakee, Illinois
The Utilization Review Nurse assesses the medical necessity of admissions and continued stays for Emergency Department patients to optimize resource utilization. They collaborate with healthcare providers and insurance companies to ensure appropriate care levels and regulatory compliance.
Riverside Healthcare is seeking a dedicated and experienced Utilization Review Nurse to join our Emergency Department team in Kankakee, Illinois.
The Utilization Review Nurse will play a crucial role in ensuring that patients receive appropriate and effective care while optimizing resource utilization.
This position involves reviewing patient cases, assessing the necessity of admissions and continued stays, and collaborating with healthcare providers to enhance patient outcomes and hospital efficiency by managing documentation and optimizing resource utilization.
Essential Duties Case Review and Assessment: Conduct thorough reviews of patient cases in the Emergency Department to assess the necessity and appropriateness of admissions, continued stays, and level of care.
Utilize clinical knowledge and evidence-based guidelines to make determinations regarding the medical necessity of services.
Collaboration and Communication: Work closely with physicians, nurses, and other healthcare professionals to gather necessary information and discuss care plans.
Communicate with insurance providers to obtain authorization for treatments and services, ensuring compliance with payer requirements.
Proactively facilitates throughput of all patients by monitoring for census peaks including surgical and procedural patient placement.
Documentation and Reporting: Maintain accurate and detailed documentation of case reviews, decisions, and communications with healthcare providers and insurance companies.
Prepare and submit reports as required, including utilization review reports and compliance documentation.
Quality Improvement: Participate in quality improvement initiatives to enhance the efficiency and effectiveness of care provided in the Emergency Department.
Analyze utilization patterns and outcomes to identify opportunities for improvement and contribute to the development of best practices.
Compliance and Policy Adherence: Ensure adherence to hospital policies, payer guidelines, and regulatory requirements related to utilization management.
Stay informed about changes in healthcare regulations and payer requirements to ensure ongoing compliance.
These are duties that MUST be performed in this job, with or without reasonable accommodation.
Non-essential Duties Assist with training and orientation of new staff members on utilization review processes and procedures.
Support administrative tasks related to the utilization review process as needed.
Participate in departmental meetings and contribute to discussions on process improvements and policy updates.
Needed for computer entry, reading memos and literature.
Needed for electrical/fire safety.
Needed for telephone communication, meetings and listening to employee concerns.
Usd $41.31 - Usd $55.28 /Hr
Candidates must be a Registered Nurse licensed in Illinois with at least 3 years of clinical experience in an Emergency Department. An Associate Degree in Nursing is required, with a Bachelor's degree preferred or required for new hires starting in 2025.
Market context
In Illinois, nursing roles typically see steady demand across hospitals, clinics, and long-term care settings, especially for candidates with an active Illinois license and current CPR certification. These positions can be competitive because employers often look for both accredited nursing education and readiness to work in fast-paced care environments. Review the AI-summarized requirements and benefits here to save time, then confirm your license, CPR status, and degree match before applying.