Utilization Review Nurse
Job Summary
The Utilization Review Nurse conducts and monitors clinical review cases to ensure the medical necessity and appropriateness of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries. This role documents all relevant information, organizes determination requests according to mandates and standards, and promotes quality, cost-effective care based on evidence.
Responsibilities
- Conduct and monitor utilization management reviews for inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries to ensure medical necessity and appropriate levels of care.
- Document all relevant and specific clinical information in accordance with organizational and regulatory standards.
- Screen, prioritize, and organize determination requests based on established mandates, standards, and timelines.
- Collaborate with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility, and appropriate service levels.
- Practice nursing within the scope of licensure while adhering to applicable policies, procedures, regulations, URAC standards, and state regulations.
- Make evidence-based decisions that support compliance, appropriate levels of care, and patient safety.
- Proactively and efficiently manage incoming and outbound calls and queues from multiple sources within required timeframes.
- Maintain current knowledge of medical and surgical procedures, products, healthcare services, drugs, and general trends in healthcare delivery, as well as internal procedures, policies, and contracts.
- Perform other related duties as assigned.
Requirements
- Active, unencumbered Registered Nurse (RN) license in the state where duties are performed.
- Bachelor of Science in Nursing (BSN) preferred.
- A minimum of four years of clinical nursing experience in at least one of the following areas: medical-surgical, surgical, intensive care, or critical care.
- Experience in utilization management and/or medical review preferred.
- Proficiency in basic computer skills, including Microsoft Word, Excel, Outlook, and navigating multiple systems.
Summary Qualification
- Licensed Registered Nurse with substantial clinical experience in acute or critical care settings.
- Background in utilization management or medical review with strong understanding of medical necessity criteria.
- Demonstrated ability to interpret complex clinical documentation and apply evidence-based guidelines.
- Proven track record of promoting patient safety, regulatory compliance, and cost-effective care.
Skill
- Strong critical thinking skills with the ability to prioritize and make sound nursing judgments.
- Excellent verbal and written communication skills.
- Ability to build and maintain collaborative relationships with internal and external stakeholders.
- High attention to detail and accuracy in documentation and review activities.
- Ability to interpret and analyze complex medical records and clinical information.
- Proficiency with Microsoft Office applications and navigating multiple computer systems.
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
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Wollborg Michelson Recruiting