RN - Utilization Management

St. Mary’s Healthcare has been providing high-quality, compassionate healthcare to the people of Montgomery and Fulton counties since 1903. At St. Mary’s Hospital, the Rao Outpatient Pavilion and other locations, the local, independent healthcare organization offers the comprehensive, critical services its community needs and deserves. St. Mary’s Healthcare has also been named a 2026 Times Union Top Workplace—the first acute care hospital in the Capital Region to earn the distinction since the Times Union launched the recognition program 15 years ago. Job Requisition: RNSPC002157 Employment Type: Full Time Shift: Days Hours Per Week: 40 hours per week Hiring range: Starting at $81,952.00 per year The actual compensation for this position will be determined based on experience and other factors permitted by law. Responsibilities: Uses clinical and coding knowledge to ensure accurate and compliant charge items and to recognize and resolve billing inconsistencies. Reviews commercial and government claim denials and audit requests and coordinates attempts to overturn denials by drafting appeals, negotiating with payers, or following up with payer utilization review departments in attempts of obtaining authorizations and claim payment. Establishes and maintains positive and cooperative relationships with medical staff and care coordination leaders to ensure ongoing compliance with utilization review guidelines. Collaborates with managed care department to code billable items for Collaborates with appropriate staff to secure information for billable items. Analyzes and creates reports to capture payer denial trends and volume, to support patient financial services and clinical leaders in the revenue cycle. Coordinates projects and audits to improve processes related to revenue cycle, efficiency of charging and billing, and collection efforts. May educate case management staff and other departments regarding payer changes and denial/appeal process. Minimum Qualifications Licensure/Certification/Registration: Required Credential(s): Registered Nurse credentialed from the New York Board of Nursing obtained prior to hire date or job transfer date. Education: Diploma from an accredited school/college of nursing required. Work Experience: None Required Skills and Attributes: Ability to organize and establish day-to-day priorities while using critical thinking skills in all aspects of the job. Must be able to multitask while remaining professional, focused, composed and positive. Excellent customer service skills Displays integrity, friendliness, and compassion. Must be able to establish an appropriate and effective rapport with others. Demonstrates flexibility Takes initiative Able to work in a fast-paced environment Embraces new opportunities to grow both personally and professionally. Effective critical thinking and problem-solving skills. Proficient with various Microsoft Office products (Word and Excel). Strong organizational skills. Effective interpersonal skills. Ability to take and follow direction in a positive and appropriate manner. Ability to work as part of a team and independently. Must be able to demonstrate effective and appropriate written and oral communication skills. Must be able to speak, read, write and follow instructions in English.