Utilization Review Nurse

We are seeking a clinically experienced Registered Nurse to join our Utilization Management team in a part-time, fully remote capacity. In this role, you'll assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization reviews - playing a critical role in ensuring patients receive appropriate, high-quality care.

What You'll Do

• Apply clinical review criteria, organizational policies, and guidelines (including ASAM and InterQual) to determine medical necessity of healthcare services
• Conduct prospective, concurrent, and retrospective utilization management reviews
• Review and evaluate treatment plans to substantiate clinical appropriateness and support quality patient outcomes
• Screen progress notes and pertinent health records to determine appropriateness for admission; perform initial and continued stay reviews
• Review case files to ensure appropriate level of care on admission and prior to discharge
• Consult with physician and practitioner consultants when reviews fail clinical criteria or guidelines
• Refer cases to other clinicians when indicated
• Document all utilization review decisions accurately in the appropriate database
• Communicate review timelines with clients, internal teams, and providers as appropriate
• Assist with appeal case preparation for medical affairs in accordance with departmental policies
• Report HIPAA or PHI violations promptly into the appropriate organizational database
• Serve as a subject matter resource for peers and care management staff on utilization review processes and questions
• Provide daily oversight and monitoring of non-clinical staff performing support activities, as appropriate, and provide supervisory input on performance
• Support quality assurance audits and other program initiatives as assigned

Please note: This role is Part time 10-20 hours weekly