Utilization Review Nurse

Reviews medical records and treatment plans to determine medical necessity, appropriateness, and efficiency of requested health care services.

• Assess clinical documentation to support coverage decisions and ensure care aligns with established standards.
• Evaluate requested services for medical necessity, appropriateness, and cost-effective utilization.
• Collaborate with physicians, members, caregivers, and care teams to coordinate care and coverage.
• Support discharge planning and identify cost-of-care options that promote compliant, effective care.
• Coordinate referrals as needed to ensure continuity of care.
• Maintain a focus on compliant decision-making and efficient health care delivery.

• Strong clinical judgment and ability to interpret medical records and treatment plans.
• Knowledge of medical necessity and utilization review principles.
• Excellent collaboration and communication skills with multidisciplinary care teams.
• Ability to make sound, cost-conscious decisions that support quality and compliance.