RN – Utilization Review

Location: East Elmhurst, NY 11370
Employment Type: Contract – 13 Weeks + Possible Extension

Pay Rate

• Travel: $2,550 – $2,630 per week
• Local: $69 – $73 per hour

Position Summary

We are seeking an experienced Registered Nurse (RN) – Utilization Review to evaluate healthcare services and medical records for medical necessity, appropriateness, and compliance with established clinical guidelines.

The ideal candidate will have prior experience in non-acute utilization review, strong clinical documentation review skills, and the ability to collaborate effectively with providers, care management teams, and other healthcare professionals.

Key Responsibilities

• Perform utilization reviews of healthcare services and medical records.
• Evaluate medical necessity and appropriateness of requested services.
• Review clinical documentation against established medical criteria and guidelines.
• Identify gaps, discrepancies, or inconsistencies in clinical documentation.
• Collaborate with providers, care management teams, and other healthcare professionals.
• Communicate review decisions and request additional clinical information when necessary.
• Maintain accurate and timely documentation of utilization review activities.
• Ensure reviews are completed in accordance with organizational, regulatory, and payer requirements.
• Apply clinical judgment and established criteria when evaluating requested services.
• Support care management and utilization management processes as needed.

Required Qualifications

• Minimum 1 year of non-acute Utilization Review experience – Required
• Active New York State RN License – Required
• AHA BLS Certification – Required
• Primary Source Verification – Required
• Registered Nurse (RN) clinical experience.
• Strong understanding of medical necessity and clinical documentation review.

Required Skills

• Utilization Review
• Utilization Management
• Registered Nurse (RN) Experience
• Medical Necessity Review
• Clinical Documentation Review
• Care Management
• Clinical Guidelines and Criteria
• Healthcare Documentation
• Provider Collaboration
• Regulatory and Payer Compliance