Utilization Review Registered Nurse (AR ONLY)

RN Utilization Management

Job Summary

The Utilization Management Nurse performs clinical reviews for prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions, and outpatient procedures. This role evaluates the efficiency and appropriateness of services for medical necessity using evidence-based criteria, clinical and corporate guidelines, policies, mandates, and standards. The nurse facilitates and promotes appropriate, high-quality care while supporting cost-effective and cost-containment measures.

Responsibilities

• Work incoming and outbound calls and queues from multiple sources within mandated requirements, managing them proactively and effectively.
• Conduct and monitor clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries.
• Document all relevant and specific clinical information and prioritize determination requests according to mandates and standards.
• Practice nursing within the scope of licensure and adhere to policies, procedures, regulations, accreditation standards, and state regulations.
• Make decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Remain current with medical and surgical procedures, products, healthcare services and drugs, general trends in healthcare delivery, and organizational procedures, policies, and contracts.
• Collaborate with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility, and appropriate service levels.
• Promote appropriate care and quality focused on cost-effective and cost-containment measures based on evidence.
• Perform other related duties as assigned.

Requirements

• Bachelor’s degree in Nursing preferred.
• Registered Nurse (RN) with an active, current, unrestricted license in good standing in the state(s) where job duties are performed.
• Minimum of four years of clinical nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care, or critical care.
• Experience in utilization management and/or medical review preferred.
• Ability to prioritize workload and make sound nursing judgments using critical thinking.
• Ability to interpret complex clinical and administrative documentation.
• Ability to work independently and build collaborative relationships.
• Proficiency with basic computer skills, including Microsoft Word, Excel, Outlook, and the ability to navigate multiple systems.

Summary Qualification

• Licensed Registered Nurse with strong clinical background in acute or critical care settings.
• Demonstrated experience in care management, utilization review, or medical review functions.
• Proven ability to apply evidence-based criteria and clinical guidelines to determine medical necessity.
• Skilled in maintaining compliance with regulatory, accreditation, and organizational standards.
• Strong collaboration skills with providers and multidisciplinary team members to support quality and cost-effective care.

Skill

• Sound clinical judgment and critical thinking.
• Analytical decision-making and problem sensitivity.
• Strong oral and written communication skills.
• Active listening and interpersonal relationship management.
• Attention to detail and time management.
• Ability to interpret and analyze complex documentation and data.
• Proficiency with Microsoft Word, Outlook, and SharePoint.
• Ability to work both independently and collaboratively in a fast-paced environment.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one’s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one’s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.

Pay: From $35.86 per hour

Work Location: Remote

Salary : $36