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Concurrent Utilization Review Nurse, RN
NeueHealth. Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines such as InterQual and MCG .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting medical necessity reviews and evaluations based on clinical guidelines such as InterQual and MCG, while ensuring compliance with health plan policies and regulatory requirements. Proficient in collaborating with healthcare teams to facilitate care transitions and optimize resource utilization.
Highest-signal resume keywords
Registered Nurse (RN)Utilization Review ExperienceClinical Guidelines KnowledgeElectronic Health Records (EHR) ProficiencyCertified Professional in Utilization Review (CPUR)
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity ReviewClinical Documentation EvaluationTreatment Plan DevelopmentAuthorization ProcessingUtilization Management
Soft Skills
Excellent CommunicationInterpersonal SkillsAnalytical SkillsAttention to Detail
Tools & Technologies
Utilization Management SoftwareMicrosoft Office Suite
Certifications & Qualifications
Registered Nurse (RN)Certified Professional in Utilization Review (CPUR)Certified Case Manager (CCM)Accredited Case Manager (ACM)
Industry Keywords
Managed CareHealth Plan PoliciesRegulatory RequirementsCare TransitionsQuality Improvement
About the role
Key responsibilities & impact- Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines such as InterQual and MCG
- Evaluate clinical documentation for level-of-care determinations, treatment plans, and continued hospital stays
- Ensure adherence to health plan policies, clinical criteria, and regulatory requirements
- Escalate complex or borderline cases to the Medical Director and provide comprehensive clinical summaries
- Collaborate with the Medical Director to develop treatment recommendations and resolve care discrepancies
- Process authorization requests for inpatient hospital, LTAC, inpatient rehabilitation, and skilled nursing admissions
- Communicate with healthcare providers to request documentation and clarify treatment plans
- Ensure timely approvals or denials of requested services
- Coordinate with case managers, social workers, and care teams to facilitate care transitions and discharge planning
- Participate in interdisciplinary discussions, team meetings, and case conferences
- Identify and escalate discharge barriers and assist transitions to outpatient or post-acute care
- Maintain accurate documentation of reviews, authorizations, denials, escalations, and Medical Director reviews
- Support quality improvement by tracking utilization trends and identifying resource optimization opportunities
- Educate providers and staff on clinical guidelines, medical necessity criteria, and authorization processes
- Stay updated on industry trends, regulatory changes, and utilization management best practices
- Meet performance metrics for review timeliness, compliance, accuracy, escalation efficiency, utilization, and cost management
Requirements
What you’ll need- Registered Nurse (RN) with an active, unrestricted California nursing license required
- Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field
- Experience in a managed care setting with medical necessity reviews is strongly preferred
- Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM)
- Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria
- Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members
- Strong analytical skills and attention to detail in reviewing clinical documentation
- Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite
Benefits
Comp & perks- Health benefits
- Life and disability benefits
- 401(k) savings plan with match
- Paid Time Off
- Paid holidays