Utilization Review Nurse

American Health Partners

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

Posted 10/28/2026full-timeFranklin • Tennessee • United StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization management, applying clinical review criteria and guidelines to assess medical necessity and quality of care. Proficient in navigating healthcare regulations and providing clinical support while maintaining confidentiality and professionalism.

Highest-signal resume keywords

Utilization Management ExperienceClinical Review Criteria ApplicationRegistered Nurse (RN) LicenseCertified Case Manager (CCM) CredentialKnowledge of Medicare Regulations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Certification TrainingInterqual UtilizationMCG UtilizationMedical Terminology KnowledgeCPT CodingICD-10 CodingHCPCS CodingCritical ThinkingDecision-MakingProblem-Solving

Soft Skills

Excellent Customer ServiceStrong Oral CommunicationStrong Written CommunicationActive ListeningAbility to Handle Multiple Priorities

Tools & Technologies

Multiple Computer Applications

Certifications & Qualifications

Registered Nurse (RN) LicenseCertified Case Manager (CCM)

Industry Keywords

Utilization ManagementAccreditation StandardsURAC PrinciplesNCQA PrinciplesHealthcare ServicesClinical Data GatheringRisk ManagementCase Management

About the role

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 level of restriction and greatest autonomy based on medical necessity
Conduct outreach to requesting providers, including specialty physicians, ancillary providers, and institutions, to gather necessary clinical data
Apply clinical review criteria, guidelines, and screens to determine medical necessity against provided clinical data
Certify cases meeting clinical review criteria, guidelines, and screens
Consult with physicians when reviews do not meet clinical review criteria, guidelines, and screens
Refer cases internally to case management and medical consultation when indicated
Adhere to accreditation, contractual, and regulatory timeframes for utilization management reviews
Ensure potential risk management issues are communicated to the Director of Medical Management or designee in a timely manner
Provide clinical support to the Clinical Services Department and Medical Director
Perform other duties as assigned

Requirements

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
Prefer clinical experience
Broad knowledge of Medicare regulations and guidance
Trained 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
Associates or better in Nursing
Strong oral and written communications skills, including active listening
Proficient in navigating through multiple computer applications
Critical thinking and decision-making skills
Successful completion of required training
Ability to handle multiple priorities effectively
Ability to make independent decisions and decisions under pressure
Maintain privacy, confidentiality, and professionalism
Ability to work independently and as part of a team

Benefits

Comp & perks

Affordable Medical/Dental/Vision insurance options
Generous paid time-off program and paid holidays for full time staff
TeleDoc 24/7/365 access to doctors
Optional short- and long-term disability plans
Employee Assistance Plan (EAP)
401K retirement accounts with company match
Employee Referral Bonus Program
Reasonable accommodations for qualified individuals with disabilities