Utilization Review Nurse

Base pay range

$35.00/hr - $45.00/hr

Direct message the job poster from Inte Pros

Inte Pros is seeking a Remote Utilization Review Nurse serves as a key clinical liaison, coordinating resources and services to meet patients’ needs while ensuring compliance with federal, state, and organizational standards. This role promotes collaboration across teams to optimize care, drive cost‑effective resource utilization, and achieve positive patient outcomes. The nurse will oversee the appropriateness of homecare admissions, resumptions of care, reauthorizations, and extended certification periods.

• Process patient prior authorization and reauthorization requests in accordance with company policies.
• Review provider documentation to determine the need for continued home health services in alignment with Medicare guidelines.
• Refer cases outside established guidelines to the Utilization Review Physician Advisor for further evaluation.
• Maintain accurate records of authorizations and communications with providers and payer plans.
• Collaborate with provider staff and care teams to identify patient needs, coordinate services, and ensure efficient use of healthcare resources.
• Monitor patient progress and outcomes to support quality and cost‑effective care delivery.
• Provide responsive customer service and facilitate communication with payer plan case managers, patients, and provider teams.
• Prepare and submit required status or summary reports in a timely manner.
• Participate in periodic weekend and holiday rotations and be available for after‑hours support related to home health management.
• Review clinical documentation to ensure compliance with CMS Chapter 7, Milliman Care Guidelines, and medical necessity requirements.
• Provide feedback to clinicians on accurate assessments, homebound status, visit utilization, and discharge planning.
• Identify and elevate quality‑of‑care issues to the Quality Assurance Committee/QPUC.
• Support the Utilization Review Committee/QPUC in resolving utilization review concerns.

• Graduate of an accredited professional nursing program (RN, LPN, or LVN).
• Minimum of two years of general nursing experience in medical, surgical, or critical care settings.
• At least one year of utilization review/management, case management, or recent home health field experience.
• Current nursing license in good standing through the Arizona Board of Nursing (and additional state boards as applicable).
• Strong organizational skills, attention to detail, and excellent oral/written communication skills.
• Proven time management skills with the ability to meet deadlines.
• Knowledge of home care regulatory and federal requirements.

• Familiarity with home health and community‑based services.
• Experience in utilization review or case management strongly preferred.
• Working knowledge of homecare, managed care, clinical procedures, and community resources.
• NCQA and URAC knowledge beneficial.
• Proficient in MS Office (Outlook, Excel, Word, Adobe) and capable of navigating multiple EMR and case management systems.

Mid‑Senior level

Contract

Quality Assurance

Hospitals and Health Care