Utilization Quality Review Nurse, Managed Care, Full-Time Days

Beacon Health System is hiring a full-time day-shift Utilization Quality Review Nurse for our Managed Care Department at Beacon Health System in Granger, IN .

Be a Beacon. Make a Difference.

At Beacon Health System, you’re not just part of a team, you’re part of something bigger. Every patient interaction is a chance to lead with compassion, build trust, and create lasting impact. Here, your expertise supports healing, and your heart connects us to the communities we serve.

• Medical, Dental, & Vision Insurance through Cigna
• Life Insurance
• 403(b) Matching Retirement Fund
• Competitive Paid Time Off (PTO)
• Shift Differentials
• Employee Assistance Program (EAP)
• Tuition and Certification Reimbursement
• Clinical Ladder Program
• Local and National Discounts
• Beacon Academy Educational Courses
• Gym Membership Discount

About Beacon Health System

Headquartered in South Bend, Indiana, as a not-for-profit, community-governed health system, Beacon Health System provides care to more than 4,000 patients each day in northern Indiana and southern Michigan.

What You’ll Do

As a Utilization Quality Review Nurse, you will report to the Director, Managed Care and Medical Director of Community Health Alliance (CHA). Conducts effective utilization and quality review through the monitoring of care provided during hospitalization and certain out-patient procedures according to utilization management guidelines for workers compensation and group accounts. Review includes pre-certification, admission, concurrent discharge and retrospective review on assigned accounts. Review may also include focused or targeted monitoring of out-patient services and physician office visits. Utilizes a case management approach. Also responsible for medical claims analysis through proper identification.

Utilization Quality Review Nurse Job Responsibilities

• Conduct utilization review and quality assurance activities, including pre-certification, concurrent review, and admission appropriateness determinations using established clinical guidelines.
• Review patient cases to identify discharge planning needs, case management opportunities, and referrals requiring physician advisor involvement.
• Educate providers on utilization management processes, quality initiatives, medical necessity criteria, and program objectives.
• Coordinate care and referrals with physicians, providers, payors, case management organizations, and other healthcare professionals to ensure appropriate and cost-effective services.
• Manage complex and high-risk cases, providing clinical analysis and facilitating referrals to external case management resources when appropriate.
• Monitor utilization trends, maintain accurate records, and prepare reports related to utilization review, quality assurance, and case management activities.
• Evaluate clinical documentation and claim decisions, assist with reconsiderations and appeals, and support resolution of utilization and coverage issues.
• Develop and maintain data collection, tracking, and reporting systems to measure utilization review and quality outcomes.
• Serve as a liaison between patients, providers, employers, payors, and internal stakeholders while maintaining compliance with HIPAA and confidentiality standards.
• Identify and escalate provider concerns, utilization issues, inappropriate billing practices, and patient complaints to leadership as needed.
• Maintain effective working relationships with physicians, provider networks, patients, and health plan partners to support program goals and operational effectiveness.
• Participate in departmental meetings, committees, quality improvement initiatives, and special projects while providing timely communication and recommendations to leadership.
• Maintain required licensure and certifications, comply with regulatory requirements and organizational policies, and perform additional duties as assigned.

What You Bring

As a Utilization Quality Review Nurse, this position requires in-depth knowledge of utilization management principles, including Milliman and Robertson criteria, medical terminology, health records systems, and managed care practices. The ideal candidate possesses strong analytical skills to evaluate utilization data, identify trends, and generate accurate reports that support operational and clinical decision-making. Success in this role also requires excellent verbal and written communication skills to effectively collaborate with patients, physicians, and healthcare teams, as well as proficiency in computer applications, data management systems, and reporting tools. The individual must be highly organized, detail-oriented, and capable of independently prioritizing workloads while utilizing available resources to achieve departmental goals.

Required Qualifications

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a nursing program from an accredited school of nursing; an undergraduate degree preferred.
• A minimum of two years experience in an acute care facility with at least one year of experience with utilization review, coding and/or case management is required.
• Previous experience with various reimbursement entities and/or claims management with a basic knowledge and understanding of Managed Health Care Programs (such as PPO, HMO, IPA, etc.) is required.

The Beacon Way

At Beacon Health System, our approach to care goes beyond clinical excellence because it’s built on meaningful connections. Guided by our core values of Trust, Respect, Integrity, and Compassion , we strive to create an environment where patients feel heard, employees feel valued, and innovation thrives.

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