Utilization Review Nurse

Job Description

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 prohibits discrimination and harassment of any kind. We are dedicated to building a diverse workforce and fostering an inclusive work environment where all employees and candidates are treated with respect and dignity. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or any other protected status under applicable law. We actively seek to recruit, develop, and retain talented individuals from diverse backgrounds and we encourage all qualified candidates to apply for our job opportunities.