We are seeking an experienced Utilization Review Registered Nurse (UR RN) to evaluate the medical necessity, appropriateness, and efficiency of healthcare services. The UR RN ensures compliance with regulatory guidelines, payer policies, and clinical standards while supporting quality patient care and cost-effective utilization of services.
Review inpatient and outpatient medical records to determine medical necessity and appropriate level of care
Apply InterQual® / MCG (Milliman) criteria and payer guidelines
Conduct concurrent, retrospective, and prospective utilization reviews
Communicate with physicians and healthcare teams regarding level-of-care determinations
Coordinate with case management, discharge planning, and care teams
Submit clinical reviews and respond to payer authorization requests
Identify overutilization, underutilization, and potential denials
Document utilization decisions accurately in UR systems
Support appeals, audits, and denial management activities
Ensure compliance with CMS, Medicare, Medicaid, and commercial payer requirements
Active Registered Nurse (RN) license (state-specific or compact)
Clinical experience in acute care, med-surg, ICU, ER, or case management
Strong knowledge of utilization review processes
Experience using InterQual or MCG criteria
Familiarity with EPIC or other EMR systems
Excellent documentation and communication skills
Prior experience in Utilization Management (UM) or UR
Knowledge of DRGs, ICD-10, and medical necessity guidelines
Experience working with health plans or hospital UR departments
Remote UR experience (if applicable)