Utilization Review Nurse Auditor

ExamWorks

. Perform quality utilization review and approve medically necessary and appropriate care according to evidence-based guidelines and criteria .

Posted 10/2/2026full-timeRemote • New Jersey • United StatesMid-LevelSenior💰 $33 - $46 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization review and medical necessity evaluation, ensuring compliance with URAC and other regulatory standards. Proficient in medical terminology and patient care, with strong organizational skills to manage documentation and client interactions effectively.

Highest-signal resume keywords

Registered Nurse LicenseUtilization Management ExperienceOASIS Coding CertificationMedical Terminology KnowledgeQuality Assurance Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ReviewPeer Review ReportingMedical Necessity EvaluationPatient CareDocumentation ManagementCoding CertificationAnatomy and Physiology KnowledgeTreatment ProtocolsLaboratory Values UnderstandingTyping Speed of 40 W.P.M.

Soft Skills

Confidentiality MaintenanceIndependent WorkTime ManagementPrioritization SkillsCustomer Service

Tools & Technologies

Microsoft SuiteDatabase ManagementFax MachineCopierScannerTelephone

Certifications & Qualifications

Registered NurseLicensed Practical NurseLicensed Vocational NurseOASIS CertificationRAC-CT CertificationCCS CertificationCPC CertificationRHIT CertificationRHIA CertificationCPMA Certification

Industry Keywords

Utilization ReviewURAC ComplianceEvidence-Based GuidelinesPatient Care StandardsQuality AssuranceMedical NecessityHealthcare RegulationsClient Complaints ManagementContinuing EducationHealthcare Documentation

About the role

Key responsibilities & impact

Perform quality utilization review and approve medically necessary and appropriate care according to evidence-based guidelines and criteria
Complete peer review reports, correspondence, addendums, and supplemental reviews
Work directly with providers to identify level, intensity, and duration of care
Document findings and evaluate medical necessity for frequency, intensity, and length of care
Ensure reviews meet industry standards and required client, federal, state, or URAC turnaround times
Maintain knowledge of URAC and other 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
Provide management with insight on 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
Current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA required
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 computer, fax, copier, scanner, and telephone
Knowledge of multiple software programs, including Microsoft Suite
Ability to maintain confidentiality
Ability to work independently, prioritize work, and use time efficiently
Ability to follow company policies and procedures

Benefits

Comp & perks

Medical, vision, and dental benefits
Paid time off
401k
Team atmosphere
Continuing education requirements and training activities