Job Description: Utilization Review Registered Nurse

Position Summary

This is a part-time position that will transition to a full-time position. The applicant must be able to work full-time within the next few months.

This is NOT a remote or hybrid position. Applicant is required to work in an office setting.

The Utilization Review (UR) Registered Nurse (RN) is responsible for ensuring the appropriate utilization of healthcare services, promoting cost-effective care, and ensuring compliance with healthcare regulations and organizational policies. This role involves evaluating medical records, coordinating with healthcare providers, and making determinations about medical necessity, treatment appropriateness, and level of care. The UR RN ensures the care delivery supports the member in achieving optimal health outcomes by coordinating appropriate services, monitoring progress, and advocating for the member’s needs throughout their healthcare journey.

Key Responsibilities

• Utilization Review
• Conduct initial pre-authorization, concurrent, and retrospective reviews for medical necessity, appropriateness, and efficiency of services for services provided across various settings, including acute care, skilled nursing facilities, outpatient clinics, and home health.
• Use industry-standard guidelines (e.g., Milliman Care Guidelines [MCG], InterQual) to assess the necessity and duration of services.
• Make recommendations regarding care delivery to align with medical necessity and insurance requirements.
• Make determinations on service approvals or escalations to Medical Directors for review.
• Care Coordination
• Evaluate medical records, physician orders, and other required clinical documents to ensure treatments align with evidence-based guidelines.
• Identify and recommend the most appropriate care settings (e.g., inpatient, outpatient, observation) based on clinical findings and insurance criteria.
• Collaborate with providers, case managers, care navigators, and members to ensure seamless transitions of care and assist in the development of discharge plans that ensure continuity of care and prevent readmissions.
• Facilitate referrals for specialized care, diagnostic services, or alternative treatment options when necessary.
• Provide education to members and providers about plan benefits and covered services.
• Submit referrals to case managers regarding members who meet case management criteria
• Insurance Authorization and Appeals
• Analyze and evaluate medical records, treatment plans, and physician recommendations to determine if a procedure, medication, or service meets insurance criteria.
• Collaborate with physicians and other healthcare providers to gather necessary information and clarify treatment plans.
• Ensure that requested services align with payer policies, clinical guidelines, and evidence-based practices.
• Prepare and provide approval or partial approval letters to providers and members for requested service, procedure, or medication.
• Prepare and provide denial or partial denial letters to providers and members for requested service, procedure, or medication.
• Prepare and present appeals for denied services by collecting and organizing medical records, provider notes, and other documents to support appeal cases.
• Draft detailed, clinically supported appeal letters to providers and members, clearly explaining the necessity of the denied service.
• Assists with peer-to-peer reviews to support authorization requests.
• Benefits & Coverage Interpretation
• Interpret plan documents/SPDs and coverage policies
• Distinguish between medial necessity vs covered benefit
• Excluded services vs prior authorization requirements
• Understand member eligibility dates
• Documentation and Reporting
• Maintain accurate and detailed records of all reviews, communications, and decisions in compliance with regulatory standards and internal policies.
• Monitor and report trends in care delivery, authorization denials, and utilization patterns to identify opportunities for process improvement.
• Assist with the preparation of reports and summaries for clients and carriers.
• Assist in the preparation of reporting for stop-loss renewal and work with stop-loss carriers to answer their questions.
• Regulatory Compliance
• Ensure adherence to state, federal, and accreditation requirements (e.g., URAC, NCQA).
• Stay updated on industry standards, clinical guidelines, and health plan policies.
• Participate in continuing education programs related to utilization management, payer regulations, and clinical guidelines.
• Stay informed about changes in diagnostic and procedural coding standards, such as updates to ICD-10, CPT, and HCPCS codes.
• Team Collaboration
• Work closely with the Medical Management team to optimize processes and improve outcomes.
• Participate in interdisciplinary meetings, training sessions, and policy reviews.
• Work with Case Managers, Care Navigators, and Director of Integrated Health Management and keep them informed of unique situations.

Qualifications

• Education:
• Active and unencumbered Registered Nurse (RN) license required.
• Bachelor’s degree in nursing (BSN) preferred.
• Experience:
• Minimum of 3 years of clinical nursing experience, preferably in case management, utilization review, or managed care settings.
• Familiarity with self-funding, insurance benefit/coverage knowledge, authorization process, specialty medications, pharmacy benefit managers, and stop-loss is preferred.
• Skills and Competencies:
• Ability to interpret History & Physical, progress notes, consult notes, lab results, imaging, operative notes, discharge summaries
• Understanding of levels of care (e.g., inpatient vs observation vs outpatient)
• Knowledge of common diagnoses, treatment plans, expected length of stay
• Understanding conservative treatment requirements (e.g., PT, meds, injections, etc.)
• Advanced clinical knowledge to assess complex medical cases.
• Able to document clear clinical rationale
• Strong critical thinking, decision-making, and problem-solving abilities.
• Excellent and professional verbal and written communication skills for interaction with diverse stakeholders.
• Confident, calm tone under pressure
• Excellent time management skills
• Maintain confidentiality (HIPAA/PHI)
• Non-biased decision-making skills
• Knowledge of clinical guidelines (e.g., InterQual, Milliman) and regulatory requirements.
• Ability to coordinate care with vendors (e.g., transplant, specialty pharmacy)
• Ability to interpret data (e.g., top drivers of high cost, provider noncompliance patterns)

Work Environment

· Primarily office-based, with collaboration with clinical teams or external stakeholders.

· May involve high-volume workloads and deadlines requiring strong organizational skills and time management.

Performance Metrics

· Accuracy and timeliness of clinical reviews and authorizations.

· Reduction in unnecessary hospital stays or procedures.

· Stakeholder satisfaction with communication and process efficiency.

Why Join Us?

As a Utilization Review RN, you will play a crucial role in driving healthcare excellence by balancing clinical expertise, patient advocacy, and cost-conscious decision-making. Your contributions will directly impact care outcomes, organizational success, and member satisfaction.

Job Types: Full-time, Part-time

Pay: From $30.00 per hour

Expected hours: 20 – 25 per week

Benefits:

• 401(k)
• Paid time off

Education:

• Bachelor's (Preferred)

Experience:

• Utilization review: 2 years (Preferred)
• Case management: 2 years (Preferred)
• clinical: 4 years (Required)

License/Certification:

• RN License (Required)

Location:

• Wichita, KS 67202 (Preferred)

Shift availability:

• Day Shift (Required)

Ability to Commute:

• Wichita, KS 67202 (Required)

Work Location: In person