Utilization Review RN – PRN

About the role

Are you an experienced RN with a strong background in hospital-based utilization review? As a PRN Utilization Review RN, you will play an important role in supporting quality patient care by conducting thorough clinical reviews to determine medical necessity, appropriate level of care, and resource utilization. Using established clinical criteria and your nursing expertise, you will perform prospective, concurrent, and retrospective utilization reviews while partnering with physicians, care management teams, health plans, and other healthcare professionals. Your clinical judgment and communication skills will help ensure patients receive the right care, at the right level, while supporting appropriate resource utilization and regulatory requirements. This is a hybrid PRN position requiring a commitment of at least two 8-hour shifts per month.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews using established clinical criteria and evidence-based guidelines to determine medical necessity and appropriate level of care.
• Review patient clinical information, including diagnoses, treatment plans, services, and length of stay, to support appropriate utilization and care delivery.
• Evaluate and validate admission status and level-of-care determinations; collaborate with Utilization Review Coordinators and other members of the care team as needed.
• Identify complex clinical or utilization issues and work collaboratively with physicians, care management teams, health plans, and other stakeholders to resolve concerns.
• Communicate with health plan representatives and physicians regarding medical necessity, clinical information, authorizations, and required documentation.
• Ensure required clinical documentation is complete, accurate, and submitted within established timeframes.
• Identify and escalate payer issues, quality concerns, potential risks, and other issues requiring leadership awareness or intervention.
• Support discharge planning, care coordination, and appropriate transitions of care through effective utilization review practices.
• Participate in the evaluation, development, and implementation of utilization management processes, protocols, policies, and procedures.
• Maintain compliance with applicable regulatory requirements, organizational policies, and established utilization review standards.
• Effectively manage multiple cases, priorities, and deadlines in a fast-paced healthcare environment.

Requirements

• Associate degree in Nursing required; Bachelor's degree in Nursing preferred.
• Current, unrestricted Registered Nurse (RN) license required.
• Minimum of three (3) years of professional nursing experience required.
• Prior hospital-based utilization review experience required.
• Nursing experience in an ICU, Med/Surg, or other acute-care hospital setting preferred.
• Experience with prospective, concurrent, and/or retrospective utilization review preferred.
• Strong knowledge of medical necessity criteria, level-of-care determination, and care coordination preferred.
• Must be available to work at least two (2) 8-hour shifts per month in this PRN role.
• Ability to work effectively in a hybrid environment.