Utilization Review Nurse

. Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan members .

Posted 10/15/2026full-timeFranklin • Tennessee • United StatesJuniorWebsite

Key responsibilities & impact

Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan members
Identify placement settings offering the lowest restriction and greatest autonomy based on medical necessity
Conduct outreach to requesting providers, specialty physicians, ancillary providers, and institutions to gather clinical data
Apply clinical review criteria, guidelines, and screens against provided clinical data
Certify cases meeting clinical review criteria, guidelines, and screens
Consult with physicians when reviews do not meet clinical criteria
Refer cases to internal professionals, including case management and medical consultation, when indicated
Adhere to accreditation, contractual, and regulatory timeframes
Notify the Director of Medical Management or designee of potential risk management issues
Provide clinical support to the Clinical Services Department and Medical Director
Perform pre-service, concurrent, and retrospective utilization management reviews
Perform other duties as assigned

What you’ll need

At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG
Clinical experience preferred
Broad knowledge of Medicare regulations and guidance
Training in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
Excellent customer service experience
Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes
Proven ability to problem-solve and make solid decisions
Current, active and unrestricted Registered Nurse (RN) license
Current Certified Case Manager (CCM) credential is a plus
Associate degree or better in Nursing
Strong oral and written communication skills, including active listening
Proficiency navigating multiple computer applications
Critical thinking and decision-making skills
Successful completion of required training
Ability to handle multiple priorities effectively and make decisions under pressure
Ability to work independently and as part of a team
Maintain privacy, confidentiality, and professionalism

Comp & perks