Registered Nurse – Utilization Review

Job Summary

The Registered Nurse (RN) – Utilization Review (UR) is a clinical and analytical role responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services. The primary goal is to ensure patients receive quality care in the most appropriate setting while optimizing resource utilization, minimizing avoidable costs, and ensuring compliance with regulatory and payer requirements.

Years of Experience: 3 year(s)

Charting System: Required, Epic

Shift: Day 5×8-Hour (08:00 – 16:30)

Travel Experience Required: Yes

Must have acute care experience!

Key Responsibilities

Clinical Review and Assessment:

Perform comprehensive prospective, concurrent, and retrospective reviews of patient medical records, clinical documentation, and treatment plans (including admissions, continued stays, procedures, and discharge plans).

Apply clinical knowledge and expertise to evaluate documentation against established medical criteria and guidelines (e.g., InterQual, Milliman Care Guidelines) to determine medical necessity and appropriate level of care.

Identify potential barriers to efficient care, such as delays in testing or treatment, and proactively intervene to facilitate patient flow.