Utilization Review Nurse

TRISTAR Insurance Group

. Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews .

Posted 10/17/2026full-timeRemote • United StatesMid-LevelSenior💰 $82,000 - $88,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management, including conducting reviews of inpatient and outpatient services, evaluating treatment requests, and adhering to state guidelines and URAC standards. Proficient in managing documentation, billing, and quality assurance while promoting cost-effective healthcare solutions.

Highest-signal resume keywords

Utilization Management ReviewsRegistered Nurse (RN) LicenseWorkers’ Compensation Utilization ReviewKnowledge of HIPAA and PHI RegulationsCCM Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical EvaluationTreatment Request EvaluationDocumentation StandardsCost-Effective Healthcare PromotionNY PAR PerformanceQuality AssuranceTime ManagementBilling RequirementsEvidence-Based GuidelinesState Guidelines

Soft Skills

Attention to DetailCommunication SkillsOrganizational SkillsProblem-Solving SkillsCollaboration

Tools & Technologies

Pharmacy PortalOnboard System

Certifications & Qualifications

CCMCMCNCPHURCPDMCOHNCDMS

Industry Keywords

Utilization ManagementInpatient ServicesOutpatient ServicesAncillary ServicesPeer Physician ReferralCase ManagementURAC StandardsInterstate Nurse Compact LicensureNY MTG GuidelinesClient-Specific Authorization Criteria

About the role

Key responsibilities & impact

Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews
Review inpatient services, outpatient services, surgeries, and ancillary service requests
Evaluate treatment requests and clinical information using state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
Identify medical necessity and refer cases to a Peer Physician when appropriate
Complete reviews within state jurisdiction and URAC timeframes
Review inpatient length of stay when applicable
Arrange alternative care services and discharge planning
Identify patients with ongoing case management needs and refer claimants to the Case Management team
Identify and review potential safety issues with the Medical Director
Promote cost-effective healthcare through an aligned provider network
Refer cases to Telephonic Case Management and Pharmacy TCM
Coordinate with TCM and Pharmacy TCM on appropriate next steps
Manage determinations within the pharmacy portal
Perform NY PAR in the onboard system according to NY MTG Guidelines
Maintain documentation standards, confidentiality, billing, productivity, time management, and quality assurance requirements
Perform other assigned duties

Requirements

What you’ll need

Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred
A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required
Interstate nurse compact licensure is preferred
May be required to obtain additional licensure based on jurisdictional assignment
CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred
Experience with Workers’ Compensation utilization review
Knowledge of state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
Knowledge of URAC timeframes and standards
Knowledge of HIPAA and PHI laws and regulations
Ability to meet productivity, time management, quality assurance, billing, and documentation requirements
Ability to perform NY PAR in the onboard system in accordance with NY MTG Guidelines

Benefits

Comp & perks

Medical, Dental, Vision Insurance
Life and Disability Insurance
401(k) Plan
Paid Holidays
Paid Time Off
Referral bonus
Fully remote work arrangement