Utilization Review Nurse

About This Role

This Utilization Review Nurse position involves evaluating the medical necessity and appropriateness of inpatient care, including making initial clinical approval determinations. The role supports care coordination, appropriate use of healthcare resources, and positive patient outcomes by collaborating with healthcare providers, patients, caregivers, and other professionals.

Responsibilities

• Evaluate the medical necessity and appropriateness of inpatient services through initial, ongoing, and follow-up clinical reviews
• Assess clinical information against established guidelines to make initial authorization decisions and identify cases requiring additional review
• Collaborate with healthcare providers and case management teams to support discharge planning and continuity of care
• Identify individuals who may benefit from care management, disease management, or social services and facilitate appropriate referrals
• Interpret healthcare benefits and assist with coordinating medically necessary services, including those outside standard coverage
• Recognize and escalate concerns involving quality of care, insurance benefits, or third-party liability
• Maintain accurate and timely clinical documentation, patient status information, and authorization records
• Communicate with patients, caregivers, healthcare providers, and internal teams to coordinate services and address care-related needs
• Assist with training and supporting new team members

Requirements

• Active, unrestricted Registered Nurse (RN) license and an associate's degree in Nursing
• Minimum of two years of full-time clinical nursing experience in acute care, community health, public health, or chronic disease management
• Experience providing patient and caregiver education related to health conditions and ongoing care
• Understanding of managed care operations, utilization management requirements, and applicable healthcare regulations
• Strong clinical knowledge of medical conditions, treatment practices, hospital operations, and healthcare delivery systems
• Ability to evaluate medical records, interpret clinical information, and apply sound judgment when assessing medical necessity
• Strong communication, critical thinking, and organizational skills, with the ability to work independently and manage competing priorities
• Working knowledge of Microsoft Office, electronic databases, and clinical documentation systems

Nice to have:

• A bachelor's degree in Nursing, Health Administration, or a related healthcare field
• Experience or knowledge in care coordination, case management, clinical review guidelines, healthcare coding, quality improvement, or community-based support resources