Utilization Review Nurse Auditor

ExamWorks

. Perform quality utilization review using acquired knowledge and evidence-based guidelines for peer review reports, correspondence, addendums, and supplemental reviews .

Posted 11/10/2026full-timeRemote • New Jersey • United StatesMid-LevelSenior💰 $33 - $46 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in utilization review and compliance with federal and state regulations, including URAC and ERISA. Possesses strong knowledge of medical terminology, treatment protocols, and the ability to manage patient care documentation effectively.

Highest-signal resume keywords

Registered Nurse LicenseUtilization Management ExperienceCPC CertificationMedical Terminology KnowledgeQuality Assurance Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ReviewMedical Necessity EvaluationPatient Care DocumentationTyping Speed of 40 W.P.M.Knowledge of Anatomy and PhysiologyTreatment ProtocolsLaboratory ValuesRegulatory ComplianceQuality Review StandardsDatabase Management

Soft Skills

Attention to DetailAbility to Work IndependentlyTeam-Oriented EnvironmentTime ManagementAdaptability to Change

Tools & Technologies

Microsoft SuiteGeneral Computer OperationsFax MachineCopierScannerTelephone

Certifications & Qualifications

Registered NurseLicensed Practical NurseLicensed Vocational NurseCPC Certification (Willingness to Obtain)OASIS CertificationRAC-CT CertificationCCS CertificationRHIT CertificationRHIA CertificationCPMA Certification

Industry Keywords

Utilization ReviewPeer ReviewFederal RegulationsState GuidelinesERISA ComplianceURAC StandardsQuality AssurancePatient CareHealthcare ComplianceEvidence-Based Guidelines

About the role

Key responsibilities & impact

Perform quality utilization review using acquired knowledge and evidence-based guidelines for peer review reports, correspondence, addendums, and supplemental reviews
Work directly with providers to identify the level, intensity, and duration of care
Document findings and continue evaluating medical necessity for frequency, intensity, and length of required care
Ensure consistency and quality of reviews meet or exceed industry standards
Complete quality reviews within required client, federal, state, or URAC-mandated turnaround times
Maintain and apply knowledge of URAC and other state and federal regulatory requirements
Maintain accurate utilization review records in the appropriate database
Direct Customer Service Representatives to ensure timely delivery of determination letters
Assist with client complaints and quality assurance issues
Ensure compliance with federal ERISA, URAC, and other state guidelines
Provide management with insight and direction regarding compliance concerns
Participate in company meetings, training activities, and continuing education
Perform other assigned duties

Requirements

What you’ll need

High school diploma or equivalent required
Graduate of an accredited nursing program
Active unencumbered Registered Nurse, Licensed Practical Nurse or Licensed Vocational Nurse required
Willingness to obtain CPC certification within the first 6 months of hire
OASIS, RAC-CT, CCS, CPC, RHIT, RHIA, or CPMA certification preferred
Three to five years of direct professional patient care required
Experience in utilization management preferred
Strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values
Qualified typist with a minimum of 40 W.P.M.
Ability to operate a general computer, fax, copier, scanner, and telephone
Knowledge of multiple software programs, including Microsoft Suite
Ability to follow instructions and respond accurately to upper management directions
Accuracy, thoroughness, responsibility for quality of work, and initiative to identify improvements
Ability to work independently, prioritize work activities, and use time efficiently
Ability to maintain confidentiality
Ability to demonstrate and promote a positive team-oriented environment
Ability to stay focused and concentrate with frequent interruptions and work under pressure or stressful conditions
Ability to manage change, delays, or unexpected events appropriately
Ability to follow all company policies and procedures

Benefits

Comp & perks

Medical insurance
Vision insurance
Dental insurance
Paid time off
401k
Competitive benefits
Continuing education requirements