Utilization Review Nurse | Full Time

Job Description – Utilization Review Nurse

Position Summary
The Utilization Review Nurse is responsible for reviewing patient admissions and ongoing hospital stays to ensure the delivery of medically necessary, appropriate, and cost-effective care. This role evaluates clinical documentation against established utilization review criteria, payer requirements, and regulatory standards while collaborating with physicians, case managers, and interdisciplinary teams to optimize patient outcomes and resource utilization.

Key Responsibilities

• Review patient admissions and continued stays for medical necessity, appropriateness of care, and compliance with payer guidelines.
• Apply InterQual and Milliman criteria to determine appropriate levels of care.
• Ensure compliance with Medicare, Medicaid, commercial insurance, and regulatory requirements.
• Analyze medical records to verify accurate clinical documentation and identify opportunities for improvement.
• Collaborate with physicians, case managers, clinical documentation specialists, and other healthcare professionals to facilitate appropriate patient care and discharge planning.
• Participate in utilization management activities, including concurrent reviews, appeals, and denial prevention.
• Maintain accurate documentation of utilization review findings and recommendations.
• Monitor resource utilization while supporting quality patient care and organizational goals.
• Stay current with healthcare regulations, accreditation standards, and utilization management best practices.

Qualifications

Education

• Graduate of an accredited School of Nursing.

Experience

• Minimum 5 years of acute care clinical nursing experience.
• At least 3 years of Utilization Management experience.
• Minimum 3 years of discharge planning experience in an acute care setting.
• Experience in Case Management or Clinical Documentation Improvement is preferred.

Licensure & Certifications

• Current, unrestricted Registered Nurse (RN) license in the State of Nevada.
• Demonstrated proficiency with InterQual criteria and ability to successfully complete the InterQual examination.
• Recent experience utilizing Milliman Care Guidelines (MCG).

Required Knowledge & Skills

• Strong understanding of utilization review principles, payer guidelines, Medicare/Medicaid regulations, and accreditation standards.
• Excellent clinical assessment and critical thinking skills.
• Ability to interpret medical records and determine medical necessity.
• Strong communication, collaboration, and interpersonal skills.
• Proficiency in electronic medical records (EMR) and Microsoft Office applications.
• Ability to prepare reports, analyze data, and communicate findings effectively.

Working Conditions

This position is primarily office-based within an acute care hospital environment and requires prolonged computer use, reviewing medical records, and frequent collaboration with clinical teams. Occasional weekend or shift work may be required based on operational needs.

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