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Utilization Review Nurse, RN – Part-Time
Job Description:
- Perform utilization management medical-necessity reviews and level-of-care determinations for requested services
- Apply benefit language, plan documents, medical policies, evidence-based criteria such as MCG and NCCN, and state/federal requirements
- Route requests that do not meet criteria to the Medical Director for secondary clinical review
- Analyze clinical documentation for completeness and identify risk, acuity indicators, inconsistencies, or missing information
- Initiate timely outreach and escalation according to utilization-management workflow
- Prioritize workload based on urgency, regulatory/accreditation time frames, and member impact
- Assist with in-network and benefit-compliant redirection by confirming eligibility, benefits, authorization requirements, and network status
- Support appeals by preparing clinical summaries and documentation and coordinating peer-to-peer/Medical Director discussions
- Document reviews, rationale, criteria or policy citations, communications, and outcomes in designated utilization-management systems
- Meet productivity, quality, accuracy, and turnaround-time standards
- Participate in calibration and quality activities and incorporate feedback
- Maintain HIPAA compliance and confidentiality
- Complete required training and annual competencies
- Cross-train and provide cross-coverage to support team operations and service-level commitments
Requirements:
- Current, unrestricted RN license in the United States or U.S. territory; compact license acceptable where applicable
- Graduate of an accredited nursing program; ADN or diploma required
- BSN preferred
- Minimum 1–2 years of recent clinical experience, such as acute care, med-surg, ICU/ED, or another relevant setting
- Prior utilization review/utilization management experience preferred
- Ability to interpret medical records and apply evidence-based criteria and plan medical policies
- Basic computer literacy upon hire
- Ability to work on multiple screens and proficient typing skills
- Proficiency with Microsoft Word, Microsoft Excel, Outlook, and similar software applications
- Excellent verbal and written communication skills
- Ability to communicate complex or technical information clearly and understand complex information from others
- Ability to work independently and use written resources to solve problems
- Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
- Ability to perform essential job functions safely and successfully, with or without reasonable accommodation
- Ability to maintain regular, punctual attendance
- Ability to sit for 6–8 hours
- Constant computer keyboard and mouse use with repetitive use of both hands
- Occasional to frequent twisting of the neck and occasional bending of the neck and waist
- Weekends required
- Up to 28 hours per week
Benefits:
- Competitive base salary and benefits effective day one
- Comprehensive medical and dental through our own health solutions
- Paid Time Off
- Mental health support
- Retirement planning
- Financial protection
- Professional development with clear career progression and learning budgets
- Mission-driven culture where diverse perspectives drive real impact
- Wellness programs
- Other employee perks
- Full benefits package starting day one