Clinical Review Nurse – Utilization Review

About the role

We are seeking a qualified Nurse to perform utilization reviews of medical cases, ensuring each request meets established medical necessity criteria. The role involves close collaboration with providers, internal teams, and client personnel to facilitate timely and compliant clinical decisions.

Key responsibilities

• Conduct utilization reviews according to HealthHelp policies, state and federal guidelines, and client agreements.
• Determine medical necessity and resolve escalated cases that require special handling.
• Document reviews in compliance with HealthHelp’s documentation policy and HIPAA regulations.
• Collaborate with physicians, medical directors, and nursing management to meet review timeframes.
• Identify and refer quality issues to Utilization Management leadership.
• Stay current with regulatory changes provided by the Compliance Department.
• Engage in phone conversations with providers, members, and internal staff to support the review process.
• Utilize multiple computer systems and software to manage cases and record findings.

Required profile

• Active nursing license and experience in utilization or case review.
• Strong knowledge of HIPAA, URAC, and NCQA standards.
• Ability to prioritize projects, work independently under pressure, and meet critical deadlines.
• Excellent communication skills for conveying clinical concepts to providers and staff.

Required skills