Utilization Review Nurse

About This Role

This fully remote role involves conducting medical necessity and utilization reviews for inpatient admissions, observation cases, and continued hospital stays. It suits Registered Nurses with acute-care experience who are looking to transition into a utilization review specialty, applying their clinical expertise to patient care decisions within a national healthcare organization.

Responsibilities

• Conduct medical necessity and utilization reviews for inpatient admissions, observation cases, and continued hospital stays
• Review clinical documentation, patient diagnoses, treatment plans, and medical records to evaluate the appropriateness of care
• Apply established medical necessity criteria, including InterQual, MCG, or other approved clinical guidelines
• Collaborate with physicians, care managers, nursing teams, and revenue cycle professionals to support appropriate patient status and treatment decisions
• Coordinate physician advisor referrals, peer-to-peer reviews, and second-level medical necessity determinations
• Identify documentation gaps, potential denials, and opportunities to improve resource utilization
• Maintain accurate and timely clinical documentation while meeting established quality and productivity expectations
• Support compliance with payer requirements, CMS guidelines, and healthcare regulations

Requirements

• Active, unrestricted Registered Nurse (RN) license
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN)
• Minimum 3 years of acute-care nursing experience
• Strong clinical assessment, critical thinking, and medical documentation skills
• Excellent communication and organizational abilities
• Ability to work independently in a fast-paced, remote environment
• Flexibility to work the required shifts, alternating weekends, and rotating holidays
• Reliable high-speed internet access

Nice to have:

• Experience in Utilization Review (UR) or Utilization Management (UM)
• Clinical background in ICU, Critical Care, Emergency Department, or Operating Room nursing
• Experience with InterQual or MCG clinical review criteria
• Inpatient case management, medical necessity review, or concurrent review experience
• Knowledge of admission status, observation versus inpatient determinations, and continued-stay reviews
• Physician advisor coordination, denials, appeals, or peer-to-peer review experience
• Compact/multistate RN license
• BSN or pediatric nursing experience

Benefits

• Annual bonus: 5% target, with potential to exceed target