Utilization Review Registered Nurse (RN)

Summary

The Utilization Review Registered Nurse is responsible for reviewing medical services to ensure they meet evidence-based guidelines and member benefit plans. This includes precertification, concurrent review, and retrospective review. The nurse works closely with providers, patients, and internal teams to support access to appropriate, medically necessary care.

Key Responsibilities

• Review medical service requests using evidence-based guidelines and plan policies
• Complete precertification, concurrent, and retrospective reviews
• Refer cases that do not meet guidelines to Physician Review
• Communicate with providers, patients, and clients to exchange certification information
• Act as a patient and family advocate to support access to appropriate care
• Identify opportunities to reduce costs while maintaining quality of care
• Refer cases for quality or post-pay review when needed
• Maintain documentation and confidentiality standards
• Participate in quality improvement activities
• Follow company policies, safety guidelines, and regulatory requirements
• Travel to client sites as needed
• Perform other duties as assigned

Required Experience, Skills and Licensure

• Minimum of 3 years of nursing experience (acute care or related setting)
• Proficiency with Microsoft 365 (Outlook, Excel, Teams)
• Strong communication, organization, and documentation skills
• Ability to work independently and manage multiple priorities
• Sound judgment and problem-solving abilities
• Comfortable working with providers, clients, and internal partners
• Active, unrestricted Registered Nurse (RN) license in Missouri
• Multistate licensure as applicable
• Valid driver’s license