Utilization Review Nurse (UR Nurse) - 25-34403
About the position The Utilization Review Nurse is responsible for monitoring and providing clinical oversight to ensure compliance with contractual, regulatory, and statutory requirements related to members’ physical/acute care and behavioral health services. This role supports appropriate utilization of healthcare services and serves as a clinical resource to internal and external stakeholders. Responsibilities • Monitor overutilization and underutilization of healthcare services • Conduct utilization reviews, case file reviews, and audits • Provide technical assistance and clinical oversight to ensure compliance with applicable regulations and guidelines • Gather, analyze, organize, and evaluate information from multiple sources, including utilization data and medical records • Coordinate care with internal teams and external providers as needed • Make referrals for medically necessary covered services • Participate in clinical staffing and interdisciplinary reviews as required • Serve as a clinical resource for utilization management and covered service determinations Requirements • Bachelor of Science in Nursing (BSN) • Minimum 2 years of experience working as a Registered Nurse • Minimum 1 year of experience in behavioral health • Active Registered Nurse (RN) license in the applicable state • FPCC certification Apply tot his job