Washington Licensed Utilization Review Nurse

Job Summary

To support healthcare quality and compliance, the full-time Washington Licensed Utilization Review Nurse will perform medical necessity reviews, collaborate with Medical Directors, and ensure adherence to clinical criteria while working remotely.

Key responsibilities

• Conducts medical necessity reviews, including prior authorizations and appropriateness of treatment settings, ensuring compliance with medical policies and member eligibility
• Consults with Medical Directors regarding cases that do not meet established criteria and documents clinical information accurately and timely
• Identifies clinical program opportunities and collaborates with various departments to ensure consistent application of clinical criteria and quality improvement initiatives

Required qualifications

• Bachelor's degree or 4 years of relevant work experience
• Current State licensure as a registered nurse
• Minimum of 3 years of clinical experience
• Utilization Management experience (preferred)
• Experience in the health plan industry (preferred)