Utilization Review Nurse

Wilson Health is seeking a full time Utilization Review Nurse to join our team.

• Access to Employer Direct Care Clinic. Free medical care and pharmacy services for eligible employees and dependents covered by Wilson Health's medical insurance plan.
• Generous paid time off (PTO) program beginning day one, designed to support work-life balance, rest, and time with family.
• Medical Insurance:
  Choose from two High
  - Deductible Health Plan (HDHP) options or a PPO plan, along with Dental and Vision coverage. Benefits begin on the first of the month following your hire date.
• HSA with employer contribution for eligible health plans; FSA for medical and dependent care expenses.
• Company-paid Life Insurance and Long-Term Disability Insurance
• Voluntary Accident, Critical Illness, and employee and dependent Life and AD&D Insurance.
• Industry-leading retirement plan – employer contributions begin day one with no waiting period for participation.
• Tuition Assistance Program
• Free access to an on‑site gym, available 24/7, making it easy to prioritize your health and wellness before or after your shift.

Position:
Utilization Review Nurse - RN – Full Time

Employment Status: Full‑Time

Department: Case Management

Hours: Monday - 8:00am - 4:30pm
- Monday
- Friday

The Utilization Review (UR) Registered Nurse is responsible for conducting prospective, concurrent, and retrospective review of patient medical records to ensure appropriate utilization of hospital services, accurate patient status, and compliance with applicable payer, regulatory, and hospital requirements.

The UR RN collaborates closely with physicians, nursing staff, case management, medical records, billing, and hospital leadership. The position plays an important role in supporting appropriate patient placement, timely documentation, quality outcomes, and reimbursement while helping ensure patients receive the right level of care in the right setting.

• Perform medical necessity and level-of-care reviews for inpatient, observation, emergency, and other applicable services.
• Review clinical documentation, physician orders, nursing documentation, diagnostic results, treatment plans, and patient progress to determine appropriateness of admission and continued stay.
• Apply established utilization review criteria, payer-specific guidelines, Medicare requirements, and hospital policies.
• Identify cases that may not meet medical necessity or level-of-care criteria and communicate concerns appropriately to physicians and the interdisciplinary care team.
• Facilitate physician-to-physician or peer-to-peer reviews with payers when necessary.
• Monitor patients concurrently throughout their hospital stay and identify barriers to continued hospitalization or discharge.
• Communicate with physicians and other members of the healthcare team regarding documentation needed to support the patient's level of care.
• Collaborate with Case Management and Social Services regarding discharge planning, transitions of care, and barriers to discharge.
• Assist with payer authorizations, concurrent review submissions, and denial prevention activities as applicable.
• Track and communicate authorization requirements and payer responses.
• Identify potential denials and work proactively with providers and hospital staff to obtain appropriate clinical documentation.
• Maintain accurate and timely utilization review records and documentation.
• Participate in denial management, appeals, and retrospective review processes as assigned.
• Monitor utilization trends and identify opportunities to improve resource utilization and patient flow.
• Assist with education of physicians and…