Utilization Review Nurse

Job Summary

To support a centralized Utilization Management department, the full-time Utilization Review Nurse will conduct timely utilization review activities, ensuring appropriate patient status determinations and compliance with regulatory requirements while working remotely.

Key responsibilities:

• Conduct medical necessity reviews and patient status determinations using approved clinical criteria and organizational policies
• Manage payer authorization processes to promote timely approvals and reduce financial risk
• Collaborate with interdisciplinary teams to support appropriate patient progression and discharge planning

Required qualifications:

• Registered Nurse license is required
• Bachelor's degree is required
• 2+ years of Acute Hospital Care experience is required
• Experience with Interqual and MCG is preferred
• Previous Utilization Management, Appeals, or Denials Management experience is preferred