RN Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse III to manage prior authorization and appeals requests while ensuring compliance with policies and procedures.

Key Responsibilities

• Review and document prior authorization and appeals requests, along with member case history
• Analyze trends and recommend revisions to medical policies and utilization management based on case reviews
• Interface with members, providers, and internal departments to ensure effective communication and coordination

Required Qualifications

• Associate's or Bachelor's degree in Nursing
• 5+ years of clinical experience beyond degree
• Active, unrestricted RN license in the state of residence
• Previous utilization management experience preferred; clinical/hospital experience considered
• Demonstrated clinical assessment skills and ability to make evidence-based decisions