Job Details
Shift: Day 5x8-Hour (08:00 - 16:30)
Description:
Position Summary:
We are seeking a detail-oriented Registered Nurse (RN) to support utilization review activities by evaluating the medical necessity, appropriateness, and efficiency of healthcare services. The RN – Utilization Review will assess clinical documentation against established guidelines, collaborate with providers and payers, and support compliance with regulatory and payer requirements while promoting quality and cost-effective patient care.
Key Responsibilities:
• Review clinical documentation to determine medical necessity and appropriateness of services
• Apply utilization review criteria (e.g., InterQual, MCG) to inpatient and outpatient cases
• Conduct concurrent, retrospective, and prospective utilization reviews
• Communicate review findings with providers, case managers, and interdisciplinary teams
• Identify potential overutilization, underutilization, or delays in care
• Support prior authorization and denial prevention processes
• Document review decisions accurately and timely in utilization management systems
• Participate in audits, quality improvement, and compliance initiatives
• Stay current with regulatory requirements, payer policies, and clinical guidelines
• Maintain patient confidentiality and adhere to professional standards
Required Qualifications:
• Active, unrestricted Registered Nurse (RN) license in the state of practice
• Associate’s or Bachelor’s degree in Nursing (BSN preferred)
• Minimum 2 years of recent clinical nursing experience required
• Prior utilization review, case management, or managed care experience preferred
• Knowledge of utilization management criteria and payer guidelines preferred
• Strong analytical, critical thinking, and documentation skills
• Excellent written and verbal communication skills
• Ability to work independently in a fast-paced, detail-oriented environment
• Proficiency with electronic medical records and utilization management systems
Pay Rate
$48.65 - $53.53/hour
About us :
At MedCadre , we’re dedicated collaborators, bridging the gap between top-tier professionals and healthcare organizations that prioritize excellence. By fostering transparent communication and leveraging deep industry expertise, we build enduring partnerships rooted in trust.
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