Utilization Review Nurse

The Utilization Review Nurse supports the health plan’s utilization management and prior authorization functions across inpatient care, outpatient services and procedures, medications, and durable medical equipment (DME). The UR Nurse reviews requests for member eligibility, benefit coverage, medical necessity, clinical appropriateness, and compliance with plan requirements; applies established clinical criteria and plan guidelines; and escalates cases requiring higher-level clinical review. The position works closely with providers, members, and internal teams to promote timely, consistent, well-documented determinations and appropriate use of health plan resources.

• Receive, review, and process utilization review and prior authorization requests across inpatient admissions and continued stays, outpatient services and procedures, diagnostic imaging, medications, and durable medical equipment (DME).
• Verify member eligibility, benefit coverage, applicable limitations or exclusions, and authorization requirements in accordance with plan documents and policies.
• Obtain and review relevant clinical documentation, including history, diagnoses, treatment plans, test results, medication history, and supporting medical records needed to evaluate requests.
• Apply MCG (Milliman Care Guidelines), plan criteria, pharmacy/formulary requirements, and other approved clinical decision-support criteria, as applicable, to evaluate medical necessity and clinical appropriateness within the scope of the position.
• Approve requests that meet established criteria and delegated authority; refer requests that do not clearly meet criteria, involve complex clinical issues, or require physician review to the appropriate clinical reviewer or Medical Director. The Specialist does not make medical-necessity denials unless specifically authorized by plan policy and applicable requirements.
• For inpatient reviews, evaluate admission information and continued-stay documentation, monitor authorized days and level of care, request additional clinical information when needed, and escalate cases involving extended stays, discharge barriers, or other clinical concerns.
• For outpatient reviews, evaluate requested procedures, therapies, imaging, and other services for benefit coverage, medical necessity, site of service, frequency, and applicable plan requirements.
• For medication reviews, evaluate prior authorization requests using applicable benefit, formulary, step-therapy, quantity-limit, and clinical criteria; obtain medication history and supporting documentation; and refer exceptions or complex requests for Medical Director review as appropriate.
• For DME reviews, evaluate requests for equipment and supplies for benefit coverage, medical necessity, appropriate coding, quantity/frequency, rental-versus-purchase requirements, and supporting documentation.
• Identify requests that may require additional coordination, including single-case agreements, specialty services, high-cost care, care management, or provider contracting, and route them to the appropriate internal resource.
• Summarize clinical information and document the rationale supporting authorization, modification, referral, or other disposition in a clear and concise manner.
• Maintain accurate and timely case notes, authorization records, status updates, and supporting documentation in the utilization management system.

• Communicate authorization status, requests for additional information, and determinations clearly, professionally, and within required timeframes to providers, members, and internal stakeholders.
• Contact provider offices and facilities to obtain missing or incomplete clinical information and follow up as needed to support timely review.
• Explain utilization management processes, plan requirements, and documentation expectations while avoiding interpretation outside the scope of the position.
• Respond to authorization-related questions, issues, and escalations promptly and route clinical, benefit, or appeal questions to the appropriate resource when necessary.

• Perform reviews in accordance with plan policies, HIPAA requirements, applicable federal and state requirements, and relevant accreditation standards, including URAC and NCQA requirements as applicable to the health plan.
• Monitor and meet required turnaround times for routine, urgent, concurrent, and retrospective reviews, as applicable.
• Maintain complete, accurate, and audit-ready documentation of review activities, communications, clinical information, and decision rationale.
• Support quality assurance activities, audits, and process improvement efforts related to utilization management and prior authorization.

• Collaborate with Care Coordination/Case Management, Claims, Member Services, Contracting/Provider Relations and the Medical Director to support coordinated and efficient review processes.
• Identify recurring utilization patterns, documentation issues, provider concerns, or workflow opportunities and share observations with leadership.
• Participate in team meetings, training, policy updates, and ongoing professional development to maintain knowledge of plan benefits, clinical criteria, coding, and utilization management practices.
• Perform other related duties as assigned to support health plan operations.

• Associate or bachelor’s degree in a healthcare-related field preferred.
• Licensed Practical Nurse (LPN) required, RN preferred. Certified Medical Assistant (CMA) or other clinical paraprofessional credential with relevant utilization management experience may be considered.
• Minimum of two years of experience in utilization review, prior authorization, medical office operations, pharmacy authorization, DME authorization, medical billing, or a related payer or provider setting.
• Experience reviewing inpatient, outpatient, medication, and/or DME requests strongly preferred.
• Familiarity with MCG, InterQual, or comparable clinical decision-support criteria preferred.
• Working knowledge of medical terminology and CPT, HCPCS, and ICD-10 coding; familiarity with medication formularies and common DME coding is desirable.

• Strong critical-thinking and analytical skills with the ability to interpret clinical documentation, apply established criteria, and recognize when escalation is required.
• Ability to distinguish clinical review requirements from benefit and coverage requirements and apply both accurately.
• Excellent verbal and written communication skills, including the ability to communicate effectively with provider offices, facilities, members, and internal teams.
• Exceptional attention to detail, organization, follow-through, and ability to manage multiple reviews with competing deadlines.
• Ability to maintain confidentiality and exercise sound judgment when handling protected health information and sensitive member information.
• Proficiency in Microsoft Office applications, including Word, Excel, and Outlook.
• Experience working with electronic utilization management, claims, electronic health record, or related healthcare systems.

• Standard office environment.
• Regular working hours are 8:00 a.m. to 5:00 p.m., Monday through Friday.
• Position is performed in the office.