Registered Nurse Utilization Review

The Registered Nurse (RN) – Utilization Review is responsible for evaluating the medical necessity and appropriateness of outpatient services to ensure quality and cost-effective patient care. This position involves applying evidence-based clinical guidelines and organizational criteria to review cases, support care management decisions, and collaborate with providers and medical directors regarding determinations and potential denials.

• Conduct utilization review for outpatient services using MCG guidelines, Client and Local Coverage Determination (LCD) criteria.
• Assess medical records and clinical documentation to determine medical necessity, level of care, and compliance with established criteria.
• Refer complex or questionable cases to the Medical Director for further review and potential denial consideration.
• Document all review activities accurately and in accordance with departmental and regulatory standards.
• Communicate with providers, case managers, and other departments to ensure continuity of care and appropriate service utilization.
• Participate in departmental meetings, audits, and quality improvement initiatives.
• Float to other departments as needed to support operational demands.

• Active Registered Nurse (RN) license in the state.
• Bachelor of Science in Nursing (BSN) degree.
• Strong knowledge of medical necessity criteria, managed care processes, and utilization management guidelines.
• Excellent analytical, critical thinking, and communication skills.
• Must have at least 2 years of recent experience in the specialty within the past 2 years.

• Previous insurance or utilization review experience.
• Familiarity with MCG (Milliman Care Guidelines), Client, and LCD criteria.
• Experience with electronic health records and case management systems.

• Basic Life Support (BLS) certification – required.
• Certified Case Manager (CCM) or Utilization Review Certification (CPUR, CPUR-CM) – preferred.>