Utilization Review Nurse

About the role

Join our Physician Advisory Services (PAS) Team and play a critical role in evaluating the medical necessity of healthcare services, treatments, and procedures to ensure patients receive appropriate, high-quality care.

Key responsibilities

• Perform admission and continued stay reviews using InterQual and MCG criteria
• Evaluate clinical documentation and ensure appropriate orders are in place
• Determine the appropriate level of care based on evidence-based guidelines
• Abstract clinical data from medical records with accuracy and attention to detail
• Support compliance with Medicare regulations and Utilization Review standards
• Collaborate with internal and external stakeholders while delivering exceptional service
• Contribute to process improvements, testing, training, and organizational growth initiatives
• Help ensure healthcare resources are utilized efficiently while supporting positive patient outcomes

Qualifications:

• Bachelor of Science in Nursing (BSN)
• Active Registered Nurse (PHRN and USRN) License
• Minimum 2 years of recent hospital-based Utilization Review or Case Management experience
• Minimum 2 years of Hospital Bedside Experience
• Experience with InterQual and/or MCG (required)
• Strong knowledge of Medicare regulations and Utilization Review processes
• Excellent clinical judgment, analytical thinking, and communication skills
• Ability to work independently with limited supervision
• Call handling experience is a plus but not required

What's in it for you:

• Competitive Pay
• Work from Home Set up
• Day 1 Benefits