Utilization Review Nurse

About the role

The Utilization Review Nurse supports the health plan’s utilization management and prior authorization functions across inpatient, outpatient, medication, and durable medical equipment services. The role ensures timely, consistent, well‑documented determinations and promotes appropriate use of health plan resources.

Key responsibilities

• Receive, review, and process utilization review and prior authorization requests for inpatient admissions, outpatient procedures, medications, and DME, verifying eligibility, coverage, and clinical necessity.
• Apply MCG, plan criteria, and pharmacy/formulary requirements to evaluate medical necessity and approve or refer requests as appropriate.
• Communicate authorization status, request additional information, and document decisions clearly to providers, members, and internal teams.
• Maintain accurate, audit‑ready case notes and meet required turnaround times for routine, urgent, concurrent, and retrospective reviews.
• Collaborate with care coordination, claims, member services, and the Medical Director to improve review processes and identify utilization patterns.

Required profile

• Licensed Practical Nurse (LPN) required; RN preferred.
• Minimum two years of experience in utilization review, prior authorization, or related payer/provider setting.
• Familiarity with MCG, InterQual, or comparable clinical decision‑support criteria.
• Working knowledge of CPT, HCPCS, and ICD‑10 coding, as well as medication formularies and DME coding.

Required skills

• Strong critical‑thinking and analytical abilities to interpret clinical documentation.
• Proficiency in Microsoft Office applications (Word, Excel, Outlook).
• Experience with electronic utilization management, claims, or EHR systems.

What we offer

• Health insurance with no employee‑paid premium, deductible, coinsurance, or copays for in‑network providers.
• On‑site clinic covering employees and family members 100%.
• 401(k) with up to 8% employer contributions and annual discretionary bonus eligibility.
• Dental, vision, life insurance and paid time off.