Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse (RN).

Key Responsibilities

• Assess medical necessity through professional reviews of treatment requests and inpatient stays
• Coordinate care transitions with hospital staff to ensure appropriate patient discharge and next-level care
• Navigate complex cases, including outpatient pre-certifications and mental health treatment reviews

Required Qualifications

• Current RN license in the United States or U.S. territory
• 1+ years of clinical experience required
• Knowledge of medical claims, ICD-10, CPT, and HCPCS coding
• Proficiency with Microsoft Office applications and electronic health systems
• Experience with MCG guidelines and clinical decision-making tools