Utilization Review RN-12

Moses Lake, Washington 98837 Posted June 20th, 2026 $ 76 per

Hour Job Type:

Contract Job Category:

Nursing Job Summary We are seeking an experienced Utilization Review Registered Nurse (UR RN) to evaluate the medical necessity, appropriateness, and efficiency of healthcare services. The UR RN ensures compliance with regulatory guidelines, payer policies, and clinical standards while supporting quality patient care and cost-effective utilization of services. Key Responsibilities Review inpatient and outpatient medical records to determine medical necessity and appropriate level of care Apply InterQual® / MCG (Milliman) criteria and payer guidelines Conduct concurrent, retrospective, and prospective utilization reviews Communicate with physicians and healthcare teams regarding level-of-care determinations Coordinate with case management, discharge planning, and care teams Submit clinical reviews and respond to payer authorization requests Identify overutilization, underutilization, and potential denials Document utilization decisions accurately in UR systems Support appeals, audits, and denial management activities Ensure compliance with CMS, Medicare, Medicaid, and commercial payer requirements Required Qualifications Active Registered Nurse (RN) license (state-specific or compact) Clinical experience in acute care, med-surg, ICU, ER, or case management Strong knowledge of utilization review processes Experience using InterQual or MCG criteria Familiarity with EPIC or other EMR systems Excellent documentation and communication skills Preferred Skills Prior experience in Utilization Management (UM) or UR Knowledge of DRGs, ICD-10, and medical necessity guidelines Experience working with health plans or hospital UR departments Remote UR experience (if applicable) #UtilizationReviewRN #URNurse #UtilizationManagement #CaseManagement #HealthcareJobs #RNJobs #RemoteRN #ClinicalReview #MedicalNecessity #InterQual #MCG #HospitalJobs #NowHiring Required Skills

REGISTERED NURSE UTILIZATION MANAGEMENT

NURSE