Utilization Review Nurse, RN – Part-Time

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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
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