Utilization Review Nurse

Key Responsibilities:

• Conduct timely and accurate reviews of inpatient and outpatient medical records to determine medical necessity and level of care.
• Apply evidence-based criteria (e.g., InterQual, MCG) and hospital policies to support clinical decision-making.
• Communicate with physicians and clinical staff to clarify documentation and support utilization decisions.
• Submit clinical reviews to insurance companies and respond to requests for additional information.
• Monitor patient status and ensure appropriate documentation for continued stay reviews.
• Maintain compliance with federal, state, and payer-specific regulations.
• Accurately document all review activities in the hospital’s electronic medical record (EMR) and UR platforms (e.g., XSOLIS/Dragonfly).

Qualifications:

• Active and unrestricted Registered Nurse (RN) license in the state of California.
• Minimum of 2 years of recent Utilization Review experience, with at least 1 year of remote UR experience within the last 12 months.
• Proficiency with XSOLIS/Dragonfly platforms.
• Strong knowledge of utilization management principles and payer requirements.
• Excellent critical thinking, communication, and time management skills.
• Ability to work independently in a remote environment with minimal supervision.