Remote Nursing Jobs • Documentation

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

Apply critical thinking and evidence-based clinical criteria to evaluate inpatient and outpatient services requiring precertification. Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information. Use established guidelines to authorize services or escalate to Medical Directors as needed.