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Utilization Review Nurse

2 weeks ago

Phoenix, AZ, United States NavitsPartners Full time
Job Title: Utilization Review Nurse (UR Nurse)

Schedule: Monday - Friday | 8:00 AM - 5:00 PM
Work Model: 100% Remote (Onsite visit required for equipment pickup)
Employment Type: Contract
Position Overview

The Utilization Review Nurse is responsible for monitoring and providing clinical oversight to ensure compliance with contractual, regulatory, and statutory requirements related to members' physical/acute care and behavioral health services. This role supports appropriate utilization of healthcare services and serves as a clinical resource to internal and external stakeholders.
Key Responsibilities
  • Monitor overutilization and underutilization of healthcare services
  • Conduct utilization reviews, case file reviews, and audits
  • Provide technical assistance and clinical oversight to ensure compliance with applicable regulations and guidelines
  • Gather, analyze, organize, and evaluate information from multiple sources, including utilization data and medical records
  • Coordinate care with internal teams and external providers as needed
  • Make referrals for medically necessary covered services
  • Participate in clinical staffing and interdisciplinary reviews as required
  • Serve as a clinical resource for utilization management and covered service determinations
Required Experience & Qualifications
  • Bachelor of Science in Nursing (BSN)
  • Minimum 2 years of experience working as a Registered Nurse
  • Minimum 1 year of experience in behavioral health
  • Active Registered Nurse (RN) license in the applicable state
  • FPCC certification
Additional Information
  • No weekends required
  • Fully remote role with limited onsite requirement for equipment setup