Registered Nurse Utilization Review

Job Summary

Working remotely on a PRN basis, the Registered Nurse Utilization Review will conduct comprehensive clinical reviews, manage complex patient cases, and support interdisciplinary teams with coding and discharge planning to ensure optimal care delivery.

Key responsibilities

• Conduct prospective, concurrent, and retrospective medical necessity reviews for admissions and service requests
• Provide specialized consultation and case management for complex patient cases
• Assist with coding accuracy, clinical documentation, and management of claim denials or appeals

Required qualifications

• Registered Nurse licensure required prior to hire or transfer date
• Diploma from an accredited school/college of nursing or required professional licensure at time of hire
• Health plan or inpatient utilization experience preferred
• Experience with InterQual or MCG preferred
• Minimum of 3 years nursing experience preferred