Utilization Review Nurse

Utilization Review Nurse

We are seeking a detail-oriented and experienced Utilization Review Nurse to evaluate the medical necessity, appropriateness, and efficiency of healthcare services. The Utilization Review Nurse will perform clinical reviews, ensure compliance with payer guidelines and regulatory requirements, collaborate with healthcare providers and case management teams, and support high-quality, cost-effective patient care. The ideal candidate is a licensed Registered Nurse (RN) with experience in utilization management, case management, or clinical nursing and a strong understanding of healthcare reimbursement and medical necessity criteria.

Key Responsibilities

Perform utilization reviews for inpatient, outpatient, observation, and post-acute care services. Assess medical necessity using established clinical guidelines such as InterQual, MCG (Milliman Care Guidelines), and payer-specific criteria. Review medical records, physician documentation, treatment plans, and diagnostic results to determine the appropriateness of healthcare services. Evaluate admissions, continued stays, transfers, and discharge plans for compliance with utilization management standards. Collaborate with physicians, case managers, discharge planners, and interdisciplinary healthcare teams to optimize patient care. Communicate with insurance companies, managed care organizations, and third-party payers regarding authorization and coverage determinations. Identify cases requiring physician advisor review or peer-to-peer discussions. Ensure compliance with CMS, Medicare, Medicaid, Joint Commission, and other regulatory requirements. Maintain accurate and timely documentation of utilization review activities and authorization decisions. Monitor resource utilization and recommend opportunities to improve quality, efficiency, and cost-effectiveness. Participate in quality improvement initiatives and utilization management committees. Stay current with healthcare regulations, payer policies, and evidence-based clinical guidelines. Assist with denial prevention, appeals, and retrospective reviews when necessary. Maintain patient confidentiality and comply with HIPAA regulations.

Required Qualifications

Active Registered Nurse (RN) license in the applicable state. Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN); BSN preferred. 2+ years of clinical nursing experience in acute care, medical-surgical, ICU, emergency department, case management, or utilization review. Experience performing utilization management or medical necessity reviews. Strong understanding of InterQual, MCG (Milliman Care Guidelines), or similar utilization review criteria. Knowledge of Medicare, Medicaid, commercial insurance, and managed care processes. Familiarity with healthcare reimbursement methodologies and prior authorization processes. Experience reviewing electronic medical records (EMR/EHR). Strong clinical assessment, critical thinking, and decision-making skills. Excellent written and verbal communication skills. Proficiency with Microsoft Office Suite and utilization management software.

Preferred Qualifications

Bachelor's degree in Nursing (BSN). Certification such as Certified Case Manager (CCM), Accredited Case Manager (ACM), or Utilization Management Certification (preferred). Experience working for hospitals, health plans, insurance companies, or managed care organizations. Knowledge of DRG reimbursement, value-based care, and population health management. Experience with denial management, appeals, and payer audits. Familiarity with Epic, Cerner, Meditech, or other electronic health record systems.

Technical Skills

Utilization Review Medical Necessity Review Case Management Clinical Documentation Review InterQual Criteria MCG (Milliman Care Guidelines) Prior Authorization Concurrent Review Retrospective Review Denial Management Appeals Management Electronic Health Records (Epic, Cerner, Meditech) Medicare & Medicaid Regulations Healthcare Reimbursement HIPAA Compliance Microsoft Office Suite

Soft Skills

Strong analytical and critical thinking abilities. Excellent communication and collaboration skills. Attention to detail and documentation accuracy. Strong organizational and time-management skills. Ability to work independently and prioritize multiple cases. Professional judgment and ethical decision-making. Problem-solving and conflict resolution skills. Commitment to patient advocacy and quality care.

Work Environment

Hospital, health system, insurance company, managed care organization, or utilization management department. Remote, hybrid, or on-site opportunities depending on employer. Regular collaboration with physicians, case managers, and payer representatives. Standard business hours with occasional on-call or weekend coverage based on organizational needs.