Utilization Review Nurse

Job Title:

Utilization Review Nurse

Reports to:

Manager, Utilization Review

The Utilization Review Nurse supports the health plan’s utilization management and prior authorization functions across inpatient care, outpatient services and procedures, medications, and durable medical equipment (DME). The UR Nurse reviews requests for member eligibility, benefit coverage, medical necessity, clinical appropriateness, and compliance with plan requirements; applies established clinical criteria and plan guidelines; and escalates cases requiring higher-level clinical review. The position works closely with providers, members, and internal teams to promote timely, consistent, well‑documented determinations and appropriate use of health plan resources.

• Receive, review, and process utilization review and prior authorization requests across inpatient admissions and continued stays, outpatient services and procedures, diagnostic imaging, medications, and durable medical equipment (DME).
• Verify member eligibility, benefit coverage, applicable limitations or exclusions, and authorization requirements in accordance with plan documents and policies.
• Obtain and review relevant clinical documentation, including history, diagnoses, treatment plans, test results, medication history, and supporting medical records needed to evaluate requests.
• Apply MCG (Milliman Care Guidelines), plan criteria, pharmacy/formulary requirements, and other approved clinical decision-support criteria, as applicable, to evaluate medical necessity and clinical appropriateness within the scope of the position.
• Approve requests that meet established criteria and delegated authority; refer requests that do not clearly meet criteria, involve complex clinical issues, or require physician review to the appropriate clinical reviewer or Medical Director. The Specialist does not make medical‑necessity denials unless specifically authorized by plan policy and applicable requirements.
• For inpatient reviews, evaluate admission information and continued‑stay documentation, monitor authorized days and level of care, request additional clinical information when needed, and escalates cases involving extended stays, discharge barriers, or other clinical concerns.
• For outpatient reviews, evaluate requested procedures, therapies, imaging, and other services for benefit coverage, medical necessity, site of service, frequency, and applicable plan requirements.
• For medication reviews, evaluate prior authorization requests using applicable benefit, formulary, step‑therapy, quantity‑limit, and clinical criteria; obtain medication history and supporting documentation; and refer exceptions or complex requests for Medical Director review as appropriate.
• For DME reviews, evaluate requests for equipment and supplies for benefit coverage, medical necessity, appropriate coding, quantity/frequency, rental‑versus‑purchase requirements, and supporting documentation.
• Identify requests that may require additional coordination, including single‑case agreements, specialty services, high‑cost care, care management, or provider contracting, and route them to the appropriate internal resource.
• Summarize clinical information and document the rationale supporting authorization, modification, referral, or other disposition in a clear and concise manner.
• Maintain accurate and timely case notes, authorization records, status updates, and supporting documentation in the utilization management system.

• Communicate authorization status, requests for additional information, and determinations clearly, professionally, and within required time frames to providers, members, and…