Concurrent Utilization Review Nurse, RN (Work from Home)

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. Key responsibilities include conducting timely reviews of inpatient and skilled nursing services, evaluating clinical documentation, collaborating with the Medical Director, processing authorization requests, supporting care coordination and discharge planning, ensuring compliance with regulations, and educating providers and staff. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.