Utilization Review Nurse

We are seeking an experienced Registered Nurse (RN) with health plan or payer-side Utilization Management (UM) experience to support clinical quality review and AI model development for prior authorization use cases. The ideal candidate will have expertise in applying evidence-based clinical criteria, such as InterQual and MCG, reviewing medical records, evaluating medical necessity, and auditing clinical annotations for accuracy and consistency. Responsibilities include identifying discrepancies, providing structured feedback, leading calibration sessions, and ensuring consistent application of clinical guidelines to improve annotation quality and AI model performance.

Key Responsibilities:

• Review, annotate, and audit clinical records and prior authorization cases for accuracy and adherence to clinical guidelines.
• Apply evidence-based criteria, including InterQual and MCG, to evaluate medical necessity and coverage determinations.
• Identify documentation gaps, annotation errors, and inconsistencies in clinical interpretations.
• Provide structured feedback to clinical reviewers and annotators to improve quality and consistency.
• Lead calibration sessions to align clinical interpretations and annotation standards.
• Monitor quality metrics, including inter-rater reliability (IRR), agreement rates, precision, recall, and F1 scores.
• Collaborate with clinical quality teams and AI/ML teams to improve annotation accuracy and model performance.
• Maintain quality audit documentation, scoring rubrics, and clinical annotation guidelines.
• Support training, mentoring, and continuous improvement initiatives for clinical annotators.

Qualifications:

• Bachelor's or Master's degree in Nursing.
• Active, unrestricted Registered Nurse (RN) license in Minnesota.
• Minimum 3 years of experience in clinical quality review, Utilization Management, or prior authorization.
• Health plan or payer-side UM experience with hands-on medical necessity reviews preferred.
• Experience applying evidence-based clinical criteria, such as InterQual and MCG.
• Strong knowledge of CPT/HCPCS, ICD-10 coding, and payer-specific medical necessity guidelines.
• Experience reviewing complex clinical documentation, including progress notes, imaging reports, referrals, and medical orders.
• Strong clinical judgment, analytical thinking, attention to detail, and communication skills.
• Prior experience with clinical annotation, AI/ML projects, quality auditing, or calibration sessions is preferred.
• Shift is 8 hrs/day Mon - Fri, 40 hrs/week
• Fully Remote Position
• Pay Range: $35 - $40 per hour

Company Description:

“Pride Health offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors”

Pride Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, sex, gender, gender identity, gender expression, sexual orientation, military status, or any other characteristic protected by applicable federal, state, or local law.

Pride Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.