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Nurse Utilization Review
Company : Catholic Health Initiatives
Location : Gilbert, AZ, 85297
Job Type : Full Time / Part Time
Salary : 49.14-49.14 HOUR
Date Posted : 3 January 2026
Job Summary and Responsibilities
Under the general direction of the Director of Care Management, performs criteria-based concurrent and retrospective utilization review to support and encourage the efficient and effective use of resources; promote quality patient care; assist with patient care management; comply with applicable standards and regulations and provide information and education to clinical care providers in order to achieve optimal clinical, financial, operational and patient satisfaction outcomes.
Skills needed:
Knowledge of federal, state and managed care rules and regulations including CMS and AHCCCS. Working knowledge with INTERQUAL or Milliman preferred. Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers.
Responsibilities:
- Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.
- Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
- Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers.
- Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
- Collaborates with facility RN Care Coordinators to ensure progression of care.
- Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.
Minimum:
- Graduate of an accredited school of nursing
- Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience
- RN: AZ or Compact License
- Ability to pass annual Inter-rater reliability test for Utilization Review product(s) used
Preferred:
- Bachelor's Degree in Nursing (BSN) or related healthcare field
- At least five (5) years of nursing experience
- Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification
- Utilization Review experience
Hello humankindness
Located conveniently in the heart of Phoenix, Arizona, St. Joseph's Hospital and Medical Center is a 571-bed, not-for-profit hospital that provides a wide range of health, social and support services. Founded in 1895 by the Sisters of Mercy, St. Joseph's was the first hospital in the Phoenix area. More than 125 years later, St. Joseph's remains dedicated to its mission of caring for the poor and underserved.
We are extremely proud to be a nationally recognized center for quality quaternary care, medical education and research. St. Joseph's includes the internationally renowned Barrow Neurological Institute, Norton Thoracic Institute, Cancer Center at St. Joseph's, Ivy Brain Tumor Center, and St. Joseph's Level I Trauma Center (which is verified by the American College of Surgeons). The hospital is also a respected center for high-risk obstetrics, neuro-rehabilitation, orthopedics, and other medical services. St. Joseph’s is considered a sought-after destination hospital for treating the most complex cases from throughout the world. Every day, approximately 20 percent of the hospital’s patients have traveled from outside of Arizona and the United States to seek treatment at St. Joseph’s.
U.S News & World Report routinely ranks St. Joseph's among the top hospitals in the United States for neurology and neurosurgery. In addition, St. Joseph's boasts the Creighton University School of Medicine at St. Joseph's, and a strategic alliance with Phoenix Children's Hospital.
St. Joseph's is consistently named an outstanding place to work and one of Arizona's healthiest employers. Come grow your career with one of Arizona's Most Admired Companies
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For the health of our community ... we are proud to be a tobacco-free campus.
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Frequently asked questions
Gilbert, AZ shows a growing demand for Nurse Utilization Review roles, especially with healthcare hubs nearby. Candidates with certifications like CCM and local RN licenses often stand out, as employers prioritize compliance and clinical experience in this competitive Arizona market.
In the Phoenix region, certifications such as Certified Case Manager (CCM) and Accredited Case Manager (ACM-RN) are highly regarded. These credentials affirm expertise in utilization review processes, aligning well with hospitals like St. Joseph's that emphasize regulatory compliance and quality patient outcomes.
Daily duties involve reviewing patient admissions and lengths of stay against established criteria, coordinating with clinical teams, and ensuring regulatory compliance. Critical thinking to assess necessity of hospitalizations and timely communication with physicians and payers are key to optimizing patient care and resource use.
By evaluating care appropriateness and resource utilization, these nurses help maintain efficient healthcare delivery. Their efforts reduce unnecessary hospital days, promote evidence-based treatment, and facilitate smooth care transitions, ultimately enhancing patient satisfaction and system sustainability.
Salaries for Nurse Utilization Review nurses in Gilbert typically range from $75,000 to $95,000 annually, influenced by experience and certifications. This pay scale reflects the specialized skills required and local healthcare market conditions, including demand for regulatory expertise and clinical acumen.
Catholic Health Initiatives emphasizes a mission-driven environment focused on underserved populations, combining clinical excellence with community care. Nurses here engage deeply with interdisciplinary teams and benefit from a culture that prioritizes quality quaternary care and professional growth.
At Catholic Health Initiatives, utilization review nurses collaborate closely with care coordinators and physicians to ensure patient stays are clinically justified. They provide education on compliance standards and facilitate communication among stakeholders, enhancing both clinical outcomes and operational efficiency.
Focus on your RN licensure, preferably Arizona or compact, acute clinical experience, and any case management certifications like CCM or ACM-RN. Demonstrating familiarity with utilization review tools such as InterQual or Milliman and strong communication skills will improve your candidacy.
Starting with acute care nursing experience builds a solid clinical foundation. Pursuing certifications in case management and seeking mentorship in utilization review units can facilitate the shift. Employers often value nursing knowledge combined with a willingness to learn utilization criteria and payer guidelines.
Challenges include balancing regulatory compliance with patient advocacy, navigating complex insurance criteria, and addressing diverse patient populations, including those traveling from outside Arizona. Nurses must exercise strong critical thinking and effective communication to manage these dynamics successfully.