Utilization Review Nurse

The ideal candidate will possess strong clinical judgment, analytical skills, and the ability to interpret clinical documentation, apply medical necessity criteria, and communicate effectively with providers, internal teams, and physician consultants to support quality patient outcomes and regulatory compliance.

• Conduct prospective, concurrent, and retrospective utilization review assessments to determine medical necessity and appropriateness of healthcare services
• Apply established clinical review criteria, organizational policies, guidelines, and screening tools including ASAM, InterQual, and other utilization management standards
• Review treatment plans, progress notes, and medical records to evaluate clinical appropriateness and quality outcomes
• Perform admission, continued stay, and discharge reviews to ensure appropriate level of care determinations
• Consult with physician and practitioner advisors when cases do not meet established clinical criteria or require escalation
• Identify cases requiring referral to additional clinical staff, care management teams, or other internal departments
• Document utilization review findings, determinations, and related case activity accurately within organizational databases and systems
• Communicate review outcomes, timelines, and relevant clinical information to providers, internal teams, and clients as appropriate
• Assist with appeal preparation and medical affairs support in accordance with organizational and departmental guidelines
• Serve as a clinical resource to peers and care management staff regarding utilization review processes, policies, and medical necessity determinations
• Provide clinical subject matter expertise and respond to provider or customer questions and concerns professionally and effectively
• Monitor compliance with HIPAA and PHI standards and report violations in accordance with organizational procedures
• Participate in quality assurance audits, process improvement initiatives, and additional program support activities as assigned
• Provide oversight and support to non-clinical staff engaged in utilization review support functions when appropriate
• Maintain compliance with regulatory requirements, payer guidelines, and organizational policies at all times
• Perform additional duties and special projects as assigned