Registered Nurse Utilization Review Specialist

Job Summary

To support effective utilization management, the part-time Senior Utilization Review Specialist will conduct concurrent and retrospective reviews of hospital services, ensuring compliance with medical necessity and payer authorization while collaborating with clinical teams in a fully remote capacity.

Key Responsibilities

• Perform concurrent and retrospective utilization reviews for inpatient, observation, and outpatient cases using approved criteria and clinical judgment
• Collaborate with physicians and care management teams to clarify documentation and support appropriate care progression while identifying and escalating potential risks
• Serve as a senior clinical resource, providing guidance on complex review questions and participating in quality audits and process improvement initiatives

Required Qualifications

• Current, unrestricted RN license
• Five or more years of acute-care hospital experience, including at least three years in utilization review or a closely related function
• Demonstrated experience applying medical-necessity and level-of-care criteria
• Working knowledge of payer authorization requirements and denial-prevention practices
• Strong clinical judgment and ability to manage a high-volume caseload independently