Staff Nurse - Utilization Review (ED)

Collegiality

Collaborates with nursing, providers, case management, finance, and payer representatives. Contributes to professional development by sharing knowledge and supporting team education.

Ethics

• Applies ethical decision-making when handling authorization issues and coverage decisions. Advocates for patient needs while balancing organizational goals and payer requirements.
• Evidence-Based
• Nursing
• Practice and
• Nursing
• Research: Applies evidence-based criteria for utilization review decisions. Supports data collection and reporting to enhance outcomes.
• Resource
• Utilization: Considers safety, effectiveness, cost, and legal compliance when recommending levels of care or authorizations. Ensures documentation supports accurate level of care and compliance standards.

Leadership

• Demonstrates leadership through decision-making, communication with multidisciplinary teams, and proactive problem-solving related to authorization and utilization challenges.
• Self-Evaluation: Reviews and reflects on own practice related to guidelines, regulations, and departmental goals.
• Safe
• Practice: Participates in maintaining a safe, efficient, and regulatory-compliant work environment; adheres to Hennepin Healthcare's protocols and confidentiality standards.
• Provide
• Education and
• Mentorship: Demonstrates knowledge and application of adult learning needs and principles. Understands, articulates, and promotes the HHS Nursing Vision and Practice Model in relation to skill set.

Qualifications

Minimum Qualifications

As of March 1, 2026, the following are required for new hires or existing employees that would move into this role: A minimum of one (1) year of Utilization Review experience is required, with at least one year occurring within the past 12 months preferred At least two (2) years of recent acute care nursing experience (med/surg, ICU, ED, etc.) required to ensure independent clinical judgement OR an approved equivalent combination of education and experience

Preferred Qualifications

BSN preferred and strongly encouraged ACM or CCM certification preferred Strong understanding of utilization review/utilization management principles Familiarity with lnterQual, MCG, or similar clinical decision-making tools License/Certifications: Possession of a valid license as a Registered Nurse issued by the State of Minnesota.