Utillization Management Nurse [PHRN]

Position Summary

The Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services across inpatient and outpatient settings. This role ensures that care aligns with clinical guidelines, payer requirements, and organizational policies — with a strong emphasis on proficiency in INTERQUAL OR MCG (Milliman Care Guidelines) for utilization management decisions.

• Conduct concurrent, retrospective, and pre-authorization reviews using MCG criteria to assess the medical necessity and level of care.
• Analyze clinical documentation and apply evidence-based standards to support utilization determinations.
• Collaborate with physicians, case managers, and other members of the care team to ensure appropriate care transitions and timely discharges.
• Communicate review outcomes to providers and payers, including approvals, denials, or requests for additional information.
• Document all reviews, determinations, and communications in accordance with internal and regulatory requirements.
• Provide guidance to clinical teams on MCG criteria and payer authorization processes.
• Participate in audits, quality improvement initiatives, and staff education related to utilization management.
• Stay up-to-date with regulatory changes, payer policies, and updates to MCG guidelines.