Concurrent Utilization Review Nurse, RN

The Concurrent Utilization Review (UR) Nurse is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan. This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.

Responsibilities

Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness; Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays; Ensure adherence to health plan policies, clinical criteria, and regulatory requirements; Review and escalate complex or borderline cases to the Medical Director; Provide the Medical Director with comprehensive clinical summaries; Collaborate with the Medical Director to develop treatment recommendations and resolve discrepancies in care; Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions; Communicate with healthcare providers to request additional documentation or clarify treatment plans; Ensure timely approvals or denials of requested services; Work closely with case managers, social workers, and care teams to facilitate seamless care transitions; Identify and escalate discharge barriers; Assist in transitioning patients from inpatient to outpatient or post-acute care settings; Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies; Maintain accurate documentation of all concurrent review activities; Support quality improvement initiatives by tracking utilization trends; Educate providers and staff on health plan clinical guidelines, medical necessity criteria, and authorization processes; Participate in interdisciplinary team meetings and case conferences

Requirements

Registered Nurse (RN) with an active, unrestricted California nursing license; Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field; Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria; Excellent communication and interpersonal skills; Strong analytical skills and attention to detail in reviewing clinical documentation; Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite

Nice to have

BSN preferred; Experience in a managed care setting with medical necessity reviews; Preferred certifications: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM); Additional clinical nursing or case management certifications

Benefits

Health benefits; Life and disability benefits; 401(k) savings plan with match; Paid Time Off; Paid holidays