Registered Nurse-Utilization Review

In the rapidly-changing, highly regulated industry that is healthcare, you need a medical staffing partner who works for you. Enter TotalMed. We’re an award-winning medical staffing agency delivering flexible healthcare staffing solutions no matter how complex your needs. But even more than that, we’re a team who really cares. Our end goal is to achieve quality patient care while enhancing your employee morale. If you’re a healthcare professional in either clinical or non-clinical healthcare, our recruiters can help you navigate the sea of healthcare jobs, uncovering your ideal career path. Or, if you’re faced with open positions and short-staffed projects in either business care or patient care, TotalMed can provide customized medical staffing solutions to fulfill your hiring requirements.

As a Utilization Review Registered Nurse (RN) supporting a health plan or insurance organization, you will use your clinical expertise to evaluate the medical necessity, appropriateness, and efficiency of healthcare services requested by providers. You'll serve as a critical liaison between healthcare providers and the health plan—helping to ensure that members receive the right care, in the right setting, at the right time. This role is a blend of clinical decision-making and administrative coordination, requiring strong communication skills and a solid understanding of medical guidelines and coverage policies.

Review prior authorization requests and clinical documentation to determine medical necessity and appropriate level of care. Apply utilization review criteria (e.g., InterQual, MCG) and plan policies to support coverage decisions. Collaborate with physicians, providers, and internal teams to obtain necessary documentation and clarify clinical details. Communicate determinations clearly and professionally to providers and members. Identify and escalate cases requiring physician review or medical director input. Document all review activities and decisions in accordance with regulatory and organizational standards. Participate in quality initiatives, audits, and policy updates to support continuous improvement.