RN - Utilization Review

Job Description

Job Description

Job Title: RN Utilization Review Position Summary

We are seeking a Utilization Review Registered Nurse (RN) to review patient records and determine the appropriateness and medical necessity of healthcare services. The RN will evaluate clinical information, support efficient resource use, and collaborate with providers and care teams.

Responsibilities

• Review medical records for medical necessity and appropriate level of care.
• Evaluate admissions, continued stays, and requested services.
• Apply clinical guidelines and utilization review criteria.
• Communicate with physicians and healthcare teams regarding patient needs.
• Identify opportunities for appropriate resource utilization.
• Coordinate with case management and insurance teams as needed.
• Document utilization review decisions and clinical findings accurately.
• Monitor patient status and changes in level of care.
• Maintain compliance with applicable policies and regulations.

Qualifications

• Active Registered Nurse (RN) license.
• Utilization review, case management, or clinical nursing experience preferred.
• Knowledge of medical necessity and clinical review processes.
• Familiarity with healthcare documentation and utilization guidelines.
• Strong analytical, communication, and organizational skills.
• Ability to work independently and meet review deadlines.