Utilization Review Nurse (Part time)

We are seeking a qualified Registered Nurse (RN) for a part-time, fully remote Utilization Review position. The ideal candidate will have previous Utilization Review (UR), ICU, critical care, or acute-care experience and be comfortable reviewing medical records, assessing medical necessity, and applying established clinical criteria to support appropriate healthcare decisions.

• Conduct utilization reviews of medical records to assess medical necessity, level of care, and appropriateness of requested healthcare services.
• Review clinical documentation, including patient history, diagnoses, treatment plans, progress notes, and other relevant medical information.
• Apply established medical necessity and utilization management criteria when evaluating services and levels of care.
• Utilize InterQual and/or Milliman criteria as applicable to complete clinical reviews.
• Evaluate whether requested services meet established clinical and organizational guidelines.
• Identify missing or additional clinical information needed to complete reviews.
• Collaborate with physicians, healthcare providers, case managers, and other clinical professionals regarding utilization decisions.
• Communicate clinical findings, recommendations, and determinations clearly and professionally.
• Accurately document all reviews, findings, and determinations in the appropriate electronic systems.
• Maintain productivity, quality, accuracy, and turnaround-time expectations.
• Manage multiple cases and competing priorities while maintaining attention to detail.
• Protect confidential patient information and comply with HIPAA and applicable privacy requirements.
• Follow organizational policies, procedures, clinical guidelines, and regulatory requirements.