RN Utilization Review Nurse

Job Summary

To support a growing healthcare organization, the full-time RN Utilization Review Nurse will conduct medical necessity reviews, escalate non-certifications for secondary clinical review, and analyze clinical records to ensure timely and compliant care decisions.

Key responsibilities

• Evaluate requested services against benefit language and medical policy to determine appropriate levels of care
• Route cases that do not meet criteria to the Medical Director for secondary clinical review
• Document reviews and outcomes in UM systems in real time to maintain a clean audit trail

Required qualifications

• Current, unrestricted RN license in the United States or a U.S. territory
• Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
• 1-2+ years of recent clinical experience in acute care, med-surg, ICU/ED, or a similar setting
• Utilization review/utilization management experience preferred
• Proficiency with Microsoft Word, Excel, and Outlook