Utilization Review Nurse, RN – Part-Time

August 27, 2026

Job Description:

Perform utilization management medical-necessity reviews and level-of-care determinations for requested services
Apply benefit language, plan documents, medical policies, evidence-based criteria such as MCG and NCCN, and state/federal requirements
Route requests that do not meet criteria to the Medical Director for secondary clinical review
Analyze clinical documentation for completeness and identify risk, acuity indicators, inconsistencies, or missing information
Initiate timely outreach and escalation according to utilization-management workflow
Prioritize workload based on urgency, regulatory/accreditation time frames, and member impact
Assist with in-network and benefit-compliant redirection by confirming eligibility, benefits, authorization requirements, and network status
Support appeals by preparing clinical summaries and documentation and coordinating peer-to-peer/Medical Director discussions
Document reviews, rationale, criteria or policy citations, communications, and outcomes in designated utilization-management systems
Meet productivity, quality, accuracy, and turnaround-time standards
Participate in calibration and quality activities and incorporate feedback
Maintain HIPAA compliance and confidentiality
Complete required training and annual competencies
Cross-train and provide cross-coverage to support team operations and service-level commitments

Requirements:

Current, unrestricted RN license in the United States or U.S. territory; compact license acceptable where applicable
Graduate of an accredited nursing program; ADN or diploma required
BSN preferred
Minimum 1–2 years of recent clinical experience, such as acute care, med-surg, ICU/ED, or another relevant setting
Prior utilization review/utilization management experience preferred
Ability to interpret medical records and apply evidence-based criteria and plan medical policies
Basic computer literacy upon hire
Ability to work on multiple screens and proficient typing skills
Proficiency with Microsoft Word, Microsoft Excel, Outlook, and similar software applications
Excellent verbal and written communication skills
Ability to communicate complex or technical information clearly and understand complex information from others
Ability to work independently and use written resources to solve problems
Knowledge of medical claims and ICD-10, CPT, and HCPCS coding
Ability to perform essential job functions safely and successfully, with or without reasonable accommodation
Ability to maintain regular, punctual attendance
Ability to sit for 6–8 hours
Constant computer keyboard and mouse use with repetitive use of both hands
Occasional to frequent twisting of the neck and occasional bending of the neck and waist
Weekends required
Up to 28 hours per week

Benefits:

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