RN Utilization Review

Job Summary

To provide timely, evidence-based utilization review services, the full-time RN Utilization Review will analyze treatment plan requests, clarify unclear requests with providers, and utilize evidence-based criteria to make determinations while working remotely.

Key responsibilities

• Identifies and analyzes treatment plan requests and associated medical records
• Utilizes evidence-based criteria to form utilization review determinations and negotiates treatment plans as necessary
• Documents utilization review outcomes and communicates with claim examiners to resolve clinical issues

Required qualifications

• Active unrestricted RN license in a state or territory of the United States
• Associate degree from an accredited college or university; Bachelor's degree preferred
• Utilization review certification preferred
• Four years of related experience, including two years of recent clinical practice or one year of recent utilization review
• Strong analytical and judgment skills to handle multiple priorities and meet deadlines