Utilization Review Nurse (RN)

Job Title: Utilization Review Nurse (RN)
Location: 100% Remote
Duration: 3–4 months+ contract

Schedule: 32–40 hours/week, CST hours, start time 8:00 AM
 
Job Summary:
Completes clinical reviews for inpatient services, verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations. Ensures members achieve optimal outcomes through integrated delivery of care across the continuum. Contributes to strategies for quality and cost-effective care.
 
Essential Job Duties:

• Assess clinical service requests to ensure optimum outcomes, cost-effectiveness, and compliance with state/federal regulations.
• Analyze clinical service requests using evidence-based clinical guidelines.
• Identify benefits, eligibility, and expected length of stay for requested treatments or procedures.
• Conduct reviews to determine prior authorization and financial responsibility.
• Process requests within required timelines.
• Refer complex cases to medical directors and present cases efficiently.
• Request additional information from members or providers as needed.
• Make referrals to other clinical programs when appropriate.
• Attend Rounds and collaborate with multidisciplinary teams to support the care model.
• Adhere to UM policies and procedures.

 
Required Qualifications / Skills:

• Active, unrestricted Registered Nurse (RN) license in Wisconsin state.
• Experience in Utilization Management (UM) / Utilization Review (UR).
• Minimum 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of education and experience.
• Knowledge of nationally recognized criteria (MCG preferred, InterQual acceptable).
• Ability to prioritize and manage multiple deadlines.
• Strong organizational, problem-solving, and critical-thinking skills.
• Excellent written and verbal communication.
• Proficiency with Microsoft Office and applicable software programs.

 
Preferred Qualifications:

• Certified Professional in Healthcare Management (CPHM).
• Recent experience in ICU or Emergency Room.
• Health Plan UM experience.