Utilization Review Nurse

Duration: 6 months contract Timing: M-F 8-5 Job Description: Reviews medical necessity and appropriateness of healthcare services using evidence-based guidelines. Performs prior authorization and concurrent reviews, analyses clinical documentation, and supports coverage determinations and discharge planning. Collaborates with providers and internal teams to ensure high-quality, cost-effective care and appropriate benefit utilization.

Examines the appropriateness and medical necessity of requested healthcare services, such as hospital admissions, procedures, tests, and therapies. Applies in-depth knowledge of clinical guidelines, protocols, and evidence-based criteria to assess the necessity and quality of healthcare services. Research opportunities to optimize resource utilization, mitigate unnecessary procedures or tests, and promote the use of cost-effective alternatives. Provides education and guidance, under close supervision, to healthcare providers regarding utilization management processes, guidelines, and documentation requirements. Reviews medical records, analyzes clinical data, and determines if services align with established guidelines and standards. Communicates with healthcare providers, insurance companies, and other stakeholders to determine the need for prior authorization of certain healthcare services. Conducts routine reviews to monitor the ongoing care of patients during their hospital stay and/or treatment. Develops programs that promote quality effectiveness of healthcare services and optimize benefit utilization. Completes clinical reports that communicate findings, monitor key performance indicators, and track the effectiveness of utilization management initiatives.