Utilization Review Registered Nurse (UR RN)

Job Description

Job Description

UTILIZATION REVIEW REGISTERED NURSE (UR RN)

Department: Integrated Health Management
Reports To: Integrated Health Management Supervisor/Manager
Clinical Oversight: Medical Director, as applicable
FLSA Status: Non-Exempt
Employment Status: Full-Time, Hourly

Salary: Based on previous work experience and years of experience

POSITION SUMMARY

EMPLOYEE IS REQUIRED TO WORK ON-SITE

The Utilization Review Registered Nurse (UR RN) performs clinical utilization review activities on behalf of health plans administered by the Third-Party Administrator (TPA). The UR RN evaluates requests for healthcare services to determine whether requested services meet established medical-necessity and utilization-management criteria and assists in ensuring services are reviewed in accordance with applicable health plan provisions, organizational policies, and regulatory requirements.

The UR RN performs prospective, concurrent, and retrospective reviews using approved evidence-based clinical criteria, applicable plan documents, clinical policies, and available medical documentation.

The UR RN collaborates with healthcare providers, facilities, the Medical Director, Case Management, Care Navigation, Claims, pharmacy/PBM partners, stop-loss resources, provider networks, and other internal and external stakeholders.

The UR RN may approve services that meet established criteria within delegated authority. Cases that do not meet established criteria or may result in an adverse medical-necessity determination are referred to the Medical Director or other appropriately qualified physician reviewer in accordance with organizational policy and applicable requirements.

ESSENTIAL JOB RESPONSIBILITIES

Utilization Review

• Perform prospective, concurrent, and retrospective utilization reviews.
  
• Review requests for inpatient and outpatient services, procedures, surgeries, diagnostic testing, therapies, durable medical equipment, specialty medications, and other services requiring utilization review or prior authorization.
  
• Review medical records and supporting clinical documentation to determine whether sufficient information is available to complete the review.
  
• Apply approved evidence-based clinical criteria consistently and appropriately.
  
• Evaluate diagnoses, treatment plans, previous treatments, laboratory findings, imaging results, physician documentation, medication history, and other relevant clinical information.
  
• Approve services that meet applicable clinical criteria and fall within delegated nursing authority.
  
• Refer cases that do not meet established criteria, involve clinical uncertainty, or may result in an adverse medical-necessity determination to the Medical Director or other qualified physician reviewer.
  
• Request additional clinical documentation from providers when necessary.
  
• Accurately document the clinical rationale and criteria used during the review.
  
• Complete reviews within applicable regulatory, contractual, plan-specific, and departmental turnaround-time requirements.
  

Prospective Review / Prior Authorization

• Review authorization requests submitted before services are rendered.
  
• Determine whether adequate clinical documentation has been submitted to support the requested service.
  
• Determine whether requests qualify for routine or urgent/expedited processing according to applicable definitions.
  
• Review clinical justification submitted for urgent requests.
  
• Apply applicable medical-necessity criteria and utilization-management requirements.
  
• Evaluate requested level of care, site of service, frequency, duration, and other relevant clinical factors.
  
• Identify opportunities for clinically appropriate alternative sites of care when applicable.
  
• Request missing clinical documentation promptly to avoid unnecessary delays.
  
• Refer cases requiring physician-level clinical judgment to the Medical Director.
  

Concurrent Review

• Conduct concurrent review of inpatient admissions and other ongoing services requiring continued authorization.
  
• Evaluate continued medical necessity and appropriateness of the current level of care.
  
• Obtain clinical updates from hospitals, facilities, and providers.
  
• Monitor treatment progression, length of stay, discharge planning, and barriers to discharge.
  
• Identify opportunities for transition to a lower level of care when clinically appropriate.
  
• Refer members with complex discharge needs, significant medical conditions, or ongoing care-coordination needs to Case Management.
  
• Escalate cases involving potential reduction or termination of previously authorized services according to established procedures.
  
• Complete continued-stay reviews within required timeframes.
  

 

Retrospective Review

• Conduct retrospective reviews when services were provided without prospective authorization or when retrospective review is otherwise appropriate.
  
• Evaluate clinical documentation based on the patient's clinical condition and information available at the time services were rendered.
  
• Apply appropriate clinical criteria and plan provisions.
  
• Document findings and recommendations.
  
• Refer cases requiring physician-level determination to the Medical Director.
  

MEDICAL DIRECTOR & PEER-TO-PEER COORDINATION

• Identify cases requiring Medical Director review.
  
• Prepare cases for physician review by organizing pertinent clinical information, applicable criteria, previous treatment, relevant plan provisions, and outstanding clinical questions.
  
• Refer potential medical-necessity denials, modifications, or other adverse clinical determinations to the appropriate physician reviewer.
  
• Coordinate peer-to-peer discussions between treating providers and physician reviewers when appropriate.
  
• Document Medical Director decisions and peer-to-peer outcomes accurately.
  
• Process resulting authorizations or other actions according to the physician's determination and established procedures.
  
• Ensure required notifications are initiated following physician review.
  
• Escalate complex or unusual clinical situations to the Supervisor, Manager, Director, and/or Medical Director as appropriate.
  

APPEALS

• Assist with utilization-management appeals as assigned.
  
• Gather medical records, previous determinations, clinical criteria, correspondence, and additional information submitted in support of the appeal.
  
• Ensure appeals are routed to appropriately qualified reviewers.
  
• Maintain awareness of appeal turnaround-time requirements and promptly escalate potential delays.
  
• Document appeal activities and outcomes accurately.
  
• Process overturned or modified determinations according to established procedures.
  
• Assist with member and provider notifications as appropriate.
  

BENEFIT & PLAN DOCUMENT REVIEW

• Review applicable Plan Documents, Summary Plan Descriptions, Adoption Agreements, amendments, schedules of benefits, exclusions, limitations, and utilization-management provisions.
  
• Identify whether requested services are subject to prior authorization or other utilization-management requirements.
  
• Recognize the distinction between a clinical medical-necessity determination and a benefit/coverage determination.
  
• Identify potential benefit exclusions, limitations, or coverage concerns during clinical review.
  
• Escalate unclear, conflicting, or complex plan-language questions to the appropriate Supervisor, Manager, Director, Claims, Compliance, or other designated resource.
  
• Avoid representing authorization as a guarantee of coverage or payment.
  
• Follow organizational requirements regarding appropriate authorization disclaimers and member/provider communications.
  

SPECIALTY MEDICATION & PBM COORDINATION

• Review specialty-medication requests when assigned and when the medication is subject to utilization-management review.
  
• Identify whether medications are subject to medical-benefit or pharmacy-benefit requirements.
  
• Identify applicable specialty-medication exclusions, prior authorization requirements, site-of-care requirements, or other plan provisions.
  
• Coordinate with PBMs, specialty pharmacies, Case Management, and other appropriate resources.
  
• Identify cases that may require evaluation for alternative funding, manufacturer assistance, PAP/MAP programs, biosimilars, specialty-pharmacy sourcing, or alternative sites of care.
  
• Escalate complex specialty-medication coverage or sourcing questions to appropriate leadership.
  
• Refer clinical questions requiring physician judgment to the Medical Director.
  

HIGH-COST CLAIM & STOP-LOSS IDENTIFICATION

The UR RN is expected to recognize utilization that may indicate significant health-plan exposure.

Responsibilities include:

• Identify potentially high-cost or catastrophic cases during utilization review.
  
• Recognize diagnoses, treatments, admissions, specialty medications, transplant cases, neonatal cases, oncology treatment, dialysis, complex surgeries, and other services that may warrant additional review or notification.
  
• Notify Case Management and appropriate leadership according to established procedures.
  
• Assist with obtaining clinical documentation needed for stop-loss reporting when requested.
  
• Follow departmental procedures regarding high-cost claimant identification and stop-loss notification.
  
• Maintain appropriate separation between financial considerations and clini