Utilization Review Nurse

About the role

The Utilization Review Nurse ensures that post‑acute care services are medically necessary, appropriately placed, and of suitable duration. Working within a health‑plan environment, the nurse collaborates with providers, facilities, and members to coordinate care across the continuum.

Key responsibilities

• Perform prospective, concurrent, and retrospective medical necessity reviews of post‑acute care services using established policies and guidelines.
• Validate appropriate setting and length of stay, and manage appeal requests from providers, facilities, and members.
• Conduct member outreach and coordinate care transitions throughout the health‑care continuum.
• Provide alternative care options for members not suitable for post‑acute services and assess discharge readiness for transitions to lower‑level care.

Required profile

• Bachelor’s degree in nursing, allied health, business, or a related field (preferred).
• 2–4 years of clinical experience in settings such as post‑acute care, home care, acute care, discharge planning, case management, or utilization review.
• Demonstrated clinical knowledge of patient care and health‑care delivery processes.
• One year of experience in a health‑insurance or managed‑care environment (preferred).
• Current, unrestricted Michigan Registered Nurse license.

Required skills

• Proficiency with InterQual clinical decision‑support tool.

What we offer

• Opportunity to impact member health outcomes within a collaborative, multidisciplinary team.
• Professional development in utilization management and care coordination.