Utilization Review Nurse - RN

Job Summary

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

Key responsibilities

• Conduct medical-necessity reviews to evaluate services against benefit language and medical policy
• Escalate non-certifications to the Medical Director, ensuring timely and defensible adverse determinations
• Analyze clinical documentation for completeness and manage a caseload based on urgency and member impact

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 similar settings
• Utilization review or utilization management experience preferred
• Proficiency with Microsoft Word, Excel, and Outlook, along with knowledge of ICD-10, CPT, and HCPCS coding