Utilization Review Nurse

Role Summary: Perform pre-service utilization reviews of medical records and treatment plans to determine whether requested services are medically necessary, appropriate, and efficient. Key Duties Review clinical documentation and proposed care plans for medical necessity, appropriateness, and efficiency. Apply clinical criteria and applicable regulatory/guideline standards to support coverage decisions. Coordinate and communicate with care teams and members to discuss coverage and available care options. Ensure decisions and documentation support compliance, quality improvement, and care management goals. Qualifications & Requirements Must reside in Washington or Idaho within commuting distance of a medical center. Strong understanding of clinical guidelines, utilization review principles, and medical record evaluation. Excellent communication and collaboration skills to partner with care teams and members. Ability to work with compliance and quality improvement expectations. #J-18808-Ljbffr Health Care Administrators Association® (HCAA)