Utilization Review Nurse

About This Role

This fully remote opportunity is for an experienced Registered Nurse (RN) with a strong background in health plan or payer-side Utilization Management (UM), prior authorization, and clinical quality review. The role involves applying evidence-based medical necessity criteria, such as InterQual and/or MCG, to review and audit clinical records and UM determinations. The selected candidate will also support AI model development by identifying annotation errors and improving reviewer consistency.

Responsibilities

• Review and audit clinical records, prior authorization cases, and UM determinations for clinical accuracy and completeness
• Apply evidence-based clinical criteria, including InterQual and/or MCG, to assess medical necessity
• Evaluate complex clinical documentation and verify appropriate application of payer policies and clinical guidelines
• Identify documentation discrepancies, annotation errors, inconsistent decisions, and ambiguous clinical cases
• Provide structured feedback to clinical reviewers and annotators to improve quality and consistency
• Monitor inter-rater reliability (IRR) and quality metrics, including reviewer agreement rates and F1 scores
• Participate in or lead clinical calibration sessions to standardize interpretation of clinical guidelines
• Collaborate remotely with clinical quality leaders, clinical annotators, and AI/ML data science teams
• Maintain quality audit records, scoring rubrics, dashboards, and training documentation
• Recommend process improvements to enhance clinical review accuracy and AI model performance
• Support training and ongoing education for clinical reviewers and annotators

Requirements

• Bachelor's or Master's degree in Nursing
• Active, unrestricted Registered Nurse (RN) license
• Minimum of 3 years of experience in clinical quality review, Utilization Management, or prior authorization
• Direct health plan or payer-side Utilization Management experience
• Hands-on experience applying InterQual and/or MCG medical necessity criteria
• Experience reviewing clinical documentation and evaluating medical necessity
• Knowledge of payer policies, coverage guidelines, and clinical review standards
• Familiarity with CPT/HCPCS and ICD-10 coding
• Strong analytical, critical-thinking, communication, and clinical judgment skills
• Ability to work independently and collaborate effectively in a remote environment
• Experience with clinical annotation, AI/ML projects, or healthcare AI model development
• Experience conducting quality audits and identifying patterns in clinical review errors
• Familiarity with inter-rater reliability, F1 scores, precision, and recall