Utilization Review Nurse (UR Nurse) - 25-34403
About the position
The Utilization Review Nurse is responsible for monitoring and providing clinical oversight to ensure compliance with contractual, regulatory, and statutory requirements related to members’ physical/acute care and behavioral health services. This role supports appropriate utilization of healthcare services and serves as a clinical resource to internal and external stakeholders.
Responsibilities
• Monitor overutilization and underutilization of healthcare services
• Conduct utilization reviews, case file reviews, and audits
• Provide technical assistance and clinical oversight to ensure compliance with applicable regulations and guidelines
• Gather, analyze, organize, and evaluate information from multiple sources, including utilization data and medical records
• Coordinate care with internal teams and external providers as needed
• Make referrals for medically necessary covered services
• Participate in clinical staffing and interdisciplinary reviews as required
• Serve as a clinical resource for utilization management and covered service determinations
Requirements
• Bachelor of Science in Nursing (BSN)
• Minimum 2 years of experience working as a Registered Nurse
• Minimum 1 year of experience in behavioral health
• Active Registered Nurse (RN) license in the applicable state
• FPCC certification
Apply tot his job
Apply To this Job