Utilization Review RN

Location: Remote working EST hours

Schedule: Friday, Saturday, Sunday, Monday: 8am-6:30pm EST or 9am-7:30pm EST

Duration: 12 Week Contract, with a high possibility of extensions or permanent hire

Join our Physician Advisory Team as a Utilization Review Author, where you will conduct first-level initial admission and continued stay case reviews. In this role, you will determine appropriate cases for review using client-specific guidelines, ensure necessary orders and clinical documentation are in place, and apply evidence-based criteria such as InterQual and MCG to support the appropriate level of care. You will abstract clinical data from a variety of medical records, maintain high standards of quality, timeliness, and productivity, and communicate effectively with both internal and external stakeholders. The ideal candidate will have a current Registered Nurse license, at least two years of recent hospital-based Utilization Review or Case Management experience, and three years of clinical nursing practice. Strong analytical, organizational, and communication skills are essential, along with knowledge of Medicare rules and experience with clinical data abstraction. Flexibility to work variable schedules, including evenings, weekends, and holidays, and a commitment to ongoing compliance and training are required.

MINIMUM QUALIFICATIONS:

• Current multi-state/compact Registered Nurse (RN) license or CA RN license
• At least 2 years of recent hospital-based Utilization Review or Case Management experience
• Minimum 3 years of clinical nursing practice experience
• Knowledge of current Medicare rules and regulations related to Utilization Review
• Strong analytical, organizational, and time management skills
• Ability to work independently with limited supervision
• Excellent written and verbal communication skills
• Proficient in clinical data abstraction with strong attention to detail
• Experience using InterQual and/or MCG evidence-based criteria
• Willingness to work variable schedules, including evenings, days, weekends, and holidays

RESPONSIBILITIES:

• Perform initial admission and continued stay reviews utilizing InterQual and MCG evidence-based criteria to determine and support the appropriate level of care
• Identify cases for review using client-specific guidelines and ensure appropriate orders and clinical documentation are in place prior to applying criteria
• Abstract clinical data from a variety of medical records to ensure accuracy and completeness
• Adhere to established quality, timeliness, and productivity standards for first-level nursing utilization review
• Communicate effectively with internal and external stakeholders while providing excellent customer service
• Complete other duties as assigned by departmental leadership, including system testing, training, and supporting organizational strategies and goals
• Maintain annual compliance and HIPAA training requirements
• Participate in organizational educational offerings and required training to support service delivery