Utilization Review Nurse

Note - Travel Experience Required Job Summary The Registered Nurse (RN) – Utilization Review is responsible for evaluating the medical necessity and appropriateness of outpatient services to ensure quality and cost-effective patient care. This position involves applying evidence-based clinical guidelines and organizational criteria to review cases, support care management decisions, and collaborate with providers and medical directors regarding determinations and potential denials. Key Responsibilities Conduct utilization review for outpatient services using MCG guidelines, Client and Local Coverage Determination (LCD) criteria. Assess medical records and clinical documentation to determine medical necessity, level of care, and compliance with established criteria. Refer complex or questionable cases to the Medical Director for further review and potential denial consideration. Document all review activities accurately and in accordance with departmental and regulatory standards. Communicate with providers, case managers, and other departments to ensure continuity of care and appropriate service utilization. Participate in departmental meetings, audits, and quality improvement initiatives. Float to other departments as needed to support operational demands. Required Qualifications Active Registered Nurse (RN) license in the state. Bachelor of Science in Nursing (BSN) degree. Strong knowledge of medical necessity criteria, managed care processes, and utilization management guidelines. Excellent analytical, critical thinking, and communication skills. Must have at least 2 years of recent experience in the specialty within the past 2 years. Preferred Qualifications (if an y) Previous insurance or utilization review experience. Familiarity with MCG (Milliman Care Guidelines), Client), and LCD criteria. Experience with electronic health records and case management systems. Certifications (if any) Basic Life Support (BLS) certification – required. Certified Case Manager (CCM) or Utilization Review Certification (CPUR, CPUR-CM) – preferred. #J-18808-Ljbffr