RN Utilization Review Lead
Job Summary
Leading a clinical team focused on timely care decisions, the full-time RN Utilization Review Lead will coach reviewers on medical-necessity criteria, monitor workflow health, and ensure documentation quality while working Monday through Friday with rotating Saturday coverage as required.
Key responsibilities
- Set daily direction for the UM team by establishing priorities and reinforcing expectations
- Coach reviewers on consistent application of medical-necessity criteria and provide real-time guidance
- Monitor workflow health and recommend solutions to address barriers affecting case turnaround
Required qualifications
- Active RN license
- Experience in utilization management, clinical review, or case management
- Background in applying medical-necessity criteria and benefit plan interpretation
- Proficiency with UM platforms and standard office/productivity tools
- Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS)
Complete Job Description
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