Utilization Review RN

Job Summary

The Utilization Review Nurse - RN reviews hospital admissions, extended stays, and supporting documentation to ensure medical necessity, appropriate level of care, and accurate clinical documentation. Under the direction of the Utilization Review leadership, this role supports concurrent review processes, facilitates authorizations, and partners with providers and staff to drive compliance with utilization policies. The UR Nurse also contributes to the development of departmental procedures, education, and performance improvement initiatives aligned with utilization review metrics.

• Conducts admission and continued stay reviews to determine medical necessity and level of care using approved screening criteria and third‑party tools.
• Collaborates with providers, care teams, and case management to ensure appropriate documentation, clinical justification, and status assignment (e.g., inpatient vs. observation).
• Facilitates authorization processes with payers for hospital admissions and ongoing services.
• Monitors and documents utilization review activities, trends, and outcomes to support regulatory and quality reporting requirements.
• Supports utilization review team performance by contributing to education, standard work, and policy/procedure development.
• Partners with internal departments to promote process improvement and compliance with UR standards and KPIs.
• Serves as a resource for best practices in documentation and utilization review for care teams.
• Participates in daily communication activities including timely review of correspondence and updates.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

• 2–4 years of clinical nursing experience required.
• 1–2 years of experience in HEDIS, MIPS, PQRS, ACO, STARS programs preferred.

• Ability to evaluate clinical documentation and make timely, independent decisions regarding medical necessity and care status.
• Proficient in utilization review processes, admission criteria, and payer authorization requirements.
• Strong interpersonal skills to collaborate with multidisciplinary teams and external partners.
• Effective written and verbal communication skills.
• Proficient in Microsoft Office (Word, Excel, PowerPoint) and Google Workspace tools.
• High attention to detail, organizational skills, and ability to manage competing priorities in a fast‑paced environment.
• Committed to patient‑centered service and continuous improvement.

• RN – Registered Nurse – State Licensure and/or Compact State Licensure required.

Mid‑Senior level

Full‑time

Health Care Provider

Hospitals and Health Care