Utilization Review Nurse
2 weeks ago
We are looking for a knowledgeable and detail-driven PH Registered Nurse to join our growing clinical review team. This role is ideal for nurses who are experienced in applying clinical guidelines such as InterQual, MCG, NCD, and LCD, and who are comfortable evaluating the medical necessity of various healthcare services.
What You'll Do
- Utilize InterQual, MCG, NCD, and LCD criteria to review inpatient and outpatient cases.
- Assess patient documentation to determine the appropriateness and necessity of recommended services.
- Work alongside medical directors and interdisciplinary teams to address complex clinical scenarios.
- Ensure all reviews meet payer, regulatory, and internal compliance standards.
- Maintain accurate, organized, and complete documentation for all case evaluations.
- Support internal quality checks, audits, and process improvement initiatives.
Who We're Looking For
- Active PHRN license (required)
- Minimum 1 year of acute bedside experience
- Clinical experience in utilization review or case management is preferred
- Strong proficiency using InterQual and MCG tools
- Solid understanding of NCD and LCD guidelines and how to apply them
- Excellent analytical and documentation skills
Work Setup
- Initial training will be conducted onsite
- Work from home after training
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