Utilization Review Nurse

Job Description

We are hiring for a Utilization Review Nurse with a managed care organization located in the US. This position is a full-time, direct hire opportunity.

Utilization Review Nurse

Location: Remote (US-based)

We are seeking an Utilization Review Nurse to evaluate the medical necessity and appropriateness of inpatient and outpatient services. This remote clinical role ensures that care decisions align with evidence-based guidelines while balancing patient advocacy with cost-effective resource utilization across the organization’s covered population.

This position is ideal for an experienced RN who wants to apply their clinical expertise in a non-bedside capacity. You will review complex medical cases daily, collaborate with physicians on care decisions, and play a direct role in ensuring patients receive appropriate and medically necessary care.

Responsibilities:

• Conduct concurrent and retrospective reviews of inpatient admissions, continued stays, and outpatient procedures using clinical criteria
• Apply InterQual, Milliman, or MCG guidelines to evaluate medical necessity and level of care appropriateness
• Collaborate with attending physicians and care teams to facilitate timely discharge planning and care transitions
• Identify cases requiring physician advisor review and prepare clinical summaries for escalation
• Monitor length of stay patterns and flag avoidable days for performance improvement tracking
• Communicate authorization decisions to providers, patients, and internal teams in a timely manner
• Maintain thorough documentation of all review activities in compliance with CMS, state, and accreditation standards
• Participate in denial prevention initiatives and peer review processes
• Review clinical documentation to assess severity of illness and intensity of service for appropriate level of care determination
• Coordinate with case management on discharge planning barriers and transition of care needs
• Support appeal reviews by providing clinical expertise and documentation for overturned denials
• Track and report on review volume, turnaround times, and denial rates by provider and service line
• Maintain current knowledge of CMS regulations, state utilization review requirements, and payer-specific guidelines
• Participate in interdisciplinary rounds and quality improvement committees as the utilization review representative

Qualifications:

• Active Registered Nurse (RN) license required
• Minimum 3 years of acute care clinical experience; utilization review or managed care experience strongly preferred
• Proficiency with InterQual, Milliman, or MCG clinical criteria sets
• Knowledge of CMS Conditions of Participation, two-midnight rule, and observation status guidelines
• Strong clinical judgment and ability to synthesize complex medical information quickly
• Excellent written and verbal communication skills for provider interactions and clinical documentation
• Experience with UM platforms and EHR systems in a review capacity
• Ability to work independently and manage a high-volume review caseload in a remote environment

Schedule:

• Full-time position
• Standard business hours
• Standard full-time hours per pay period

Salary Range: The salary range for this position is approximately $78,000 – $92,000 annually ($37.50 – $44.23 per hour), based on experience and qualifications. Relocation assistance may be available for qualified candidates.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.