Utilization Review Nurse

We are seeking a Utilization Review RN to assess the medical necessity, quality, and appropriateness of healthcare services through prospective, concurrent, and retrospective reviews. This role collaborates with providers and internal teams to ensure compliance with clinical guidelines and optimal patient outcomes.

Responsibilities:

• Apply clinical criteria (InterQual, ASAM, and internal guidelines) to determine appropriate level of care
• Perform admission, continued stay, and discharge reviews
• Review medical records and treatment plans for clinical appropriateness
• Document review decisions in database systems
• Collaborate with physicians when cases do not meet criteria
• Assist with appeals, audits, and quality assurance activities
• Communicate effectively with internal teams, clients, and providers
• Provide guidance to non-clinical staff as needed