Utilization Review Nurse - Remote

Overview

The Utilization Review Nurse is responsible for the medical necessity review of outpatient services that require prior authorization, and/or management of concurrent inpatient admissions, ensuring compliance with state and federal regulations.

In Short

• Perform utilization reviews using evidence-based guidelines.
• Evaluate severity of illness and service intensity at admission.
• Triage and prioritize cases to meet CMS standards.
• Prepare and escalate cases for MD review as needed.
• Maintain effective communication with medical staff and clients.
• Establish relationships with providers for service coordination.
• Keep accurate records of UR activities.
• Adhere to quality standards and confidentiality policies.
• Ensure compliance with regulations in daily activities.
• Adapt to changes in policies and responsibilities.

Requirements

• Licensed RN or LPN required.
• 2-3 years of clinical experience required.
• Managed care experience preferred.
• Ability to read and interpret documents.
• Excellent oral and written communication skills.
• Proficient in MS Office.
• Strong customer service skills.
• InterQual experience is helpful.

Benefits

• People-first approach to work culture.
• Engagement and empowerment of team members.
• Opportunities for professional development.
• Supportive team environment.