Utilization Review Registered Nurse (UR RN)

UTILIZATION REVIEW REGISTERED NURSE (UR RN)

Department: Integrated Health Management
Reports To: Integrated Health Management Supervisor/Manager
Clinical Oversight: Medical Director, as applicable
FLSA Status: Non-Exempt
Employment Status: Full-Time, Hourly

Salary: Based on previous work experience and years of experience

POSITION SUMMARY  

EMPLOYEE IS REQUIRED TO WORK ON-SITE

The Utilization Review Registered Nurse (UR RN) performs clinical utilization review activities on behalf of health plans administered by the Third-Party Administrator (TPA). The UR RN evaluates requests for healthcare services to determine whether requested services meet established medical-necessity and utilization-management criteria and assists in ensuring services are reviewed in accordance with applicable health plan provisions, organizational policies, and regulatory requirements.

The UR RN performs prospective, concurrent, and retrospective reviews using approved evidence-based clinical criteria, applicable plan documents, clinical policies, and available medical documentation.

The UR RN collaborates with healthcare providers, facilities, the Medical Director, Case Management, Care Navigation, Claims, pharmacy/PBM partners, stop-loss resources, provider networks, and other internal and external stakeholders.

The UR RN may approve services that meet established criteria within delegated authority. Cases that do not meet established criteria or may result in an adverse medical-necessity determination are referred to the Medical Director or other appropriately qualified physician reviewer in accordance with organizational policy and applicable requirements.

ESSENTIAL JOB RESPONSIBILITIES

Utilization Review

• Perform prospective, concurrent, and retrospective utilization reviews.
  
• Review requests for inpatient and outpatient services, procedures, surgeries, diagnostic testing, therapies, durable medical equipment, specialty medications, and other services requiring utilization review or prior authorization.
  
• Review medical records and supporting clinical documentation to determine whether sufficient information is available to complete the review.
  
• Apply approved evidence-based clinical criteria consistently and appropriately.
  
• Evaluate diagnoses, treatment plans, previous treatments, laboratory findings, imaging results, physician documentation, medication history, and other relevant clinical information.
  
• Approve services that meet applicable clinical criteria and fall within delegated nursing authority.
  
• Refer cases that do not meet established criteria, involve clinical uncertainty, or may result in an adverse medical-necessity determination to the Medical Director or other qualified physician reviewer.
  
• Request additional clinical documentation from providers when necessary.
  
• Accurately document the clinical rationale and criteria used during the review.
  
• Complete reviews within applicable regulatory, contractual, plan-specific, and departmental turnaround-time requirements.
  

Prospective Review / Prior Authorization

• Review authorization requests submitted before services are rendered.
  
• Determine whether adequate clinical documentation has been submitted to support the requested service.
  
• Determine whether requests qualify for routine or urgent/expedited processing according to applicable definitions.
  
• Review clinical justification submitted for urgent requests.
  
• Apply applicable medical-necessity criteria and utilization-management requirements.
  
• Evaluate requested level of care, site of service, frequency, duration, and other relevant clinical factors.
  
• Identify opportunities for clinically appropriate alternative sites of care when applicable.
  
• Request missing clinical documentation promptly to avoid unnecessary delays.
  
• Refer cases requiring physician-level clinical judgment to the Medical Director.
  

Concurrent Review

• Conduct concurrent review of inpatient admissions and other ongoing services requiring continued authorization.
  
• Evaluate continued medical necessity and appropriateness of the current level of care.
  
• Obtain clinical updates from hospitals, facilities, and providers.
  
• Monitor treatment progression, length of stay, discharge planning, and barriers to discharge.
  
• Identify opportunities for transition to a lower level of care when clinically appropriate.
  
• Refer members with complex discharge needs, significant medical conditions, or ongoing care-coordination needs to Case Management.
  
• Escalate cases involving potential reduction or termination of previously authorized services according to established procedures.
  
• Complete continued-stay reviews within required timeframes.
  

Retrospective Review

• Conduct retrospective reviews when services were provided without prospective authorization or when retrospective review is otherwise appropriate.
  
• Evaluate clinical documentation based on the patient's clinical condition and information available at the time services were rendered.
  
• Apply appropriate clinical criteria and plan provisions.
  
• Document findings and recommendations.
  
• Refer cases requiring physician-level determination to the Medical Director.
  

MEDICAL DIRECTOR & PEER-TO-PEER COORDINATION

• Identify cases requiring Medical Director review.
  
• Prepare cases for physician review by organizing pertinent clinical information, applicable criteria, previous treatment, relevant plan provisions, and outstanding clinical questions.
  
• Refer potential medical-necessity denials, modifications, or other adverse clinical determinations to the appropriate physician reviewer.
  
• Coordinate peer-to-peer discussions between treating providers and physician reviewers when appropriate.
  
• Document Medical Director decisions and peer-to-peer outcomes accurately.
  
• Process resulting authorizations or other actions according to the physician's determination and established procedures.
  
• Ensure required notifications are initiated following physician review.
  
• Escalate complex or unusual clinical situations to the Supervisor, Manager, Director, and/or Medical Director as appropriate.
  

APPEALS

• Assist with utilization-management appeals as assigned.
  
• Gather medical records, previous determinations, clinical criteria, correspondence, and additional information submitted in support of the appeal.
  
• Ensure appeals are routed to appropriately qualified reviewers.
  
• Maintain awareness of appeal turnaround-time requirements and promptly escalate potential delays.
  
• Document appeal activities and outcomes accurately.
  
• Process overturned or modified determinations according to established procedures.
  
• Assist with member and provider notifications as appropriate.
  

 BENEFIT & PLAN DOCUMENT REVIEW

• Review applicable Plan Documents, Summary Plan Descriptions, Adoption Agreements, amendments, schedules of benefits, exclusions, limitations, and utilization-management provisions.
  
• Identify whether requested services are subject to prior authorization or other utilization-management requirements.
  
• Recognize the distinction between a clinical medical-necessity determination and a benefit/coverage determination.
  
• Identify potential benefit exclusions, limitations, or coverage concerns during clinical review.
  
• Escalate unclear, conflicting, or complex plan-language questions to the appropriate Supervisor, Manager, Director, Claims, Compliance, or other designated resource.
  
• Avoid representing authorization as a guarantee of coverage or payment.
  
• Follow organizational requirements regarding appropriate authorization disclaimers and member/provider communications.
  

SPECIALTY MEDICATION & PBM COORDINATION

• Review specialty-medication requests when assigned and when the medication is subject to utilization-management review.
  
• Identify whether medications are subject to medical-benefit or pharmacy-benefit requirements.
  
• Identify applicable specialty-medication exclusions, prior authorization requirements, site-of-care requirements, or other plan provisions.
  
• Coordinate with PBMs, specialty pharmacies, Case Management, and other appropriate resources.
  
• Identify cases that may require evaluation for alternative funding, manufacturer assistance, PAP/MAP programs, biosimilars, specialty-pharmacy sourcing, or alternative sites of care.
  
• Escalate complex specialty-medication coverage or sourcing questions to appropriate leadership.
  
• Refer clinical questions requiring physician judgment to the Medical Director.
  

HIGH-COST CLAIM & STOP-LOSS IDENTIFICATION

The UR RN is expected to recognize utilization that may indicate significant health-plan exposure.

Responsibilities include:

• Identify potentially high-cost or catastrophic cases during utilization review.
  
• Recognize diagnoses, treatments, admissions, specialty medications, transplant cases, neonatal cases, oncology treatment, dialysis, complex surgeries, and other services that may warrant additional review or notification.
  
• Notify Case Management and appropriate leadership according to established procedures.
  
• Assist with obtaining clinical documentation needed for stop-loss reporting when requested.
  
• Follow departmental procedures regarding high-cost claimant identification and stop-loss notification.
  
• Maintain appropriate separation between financial considerations and clinical medical-necessity determinations.
  

CASE MANAGEMENT & CARE NAVIGATION REFERRALS

Identify and refer members who may benefit from additional support, including members experiencing:

• Complex or chronic medical conditions
  
• Multiple hospitalizations or emergency department visits
  
• High-cost diagnoses or treatments
  
• Newly diagnosed serious conditions
  
• Oncology treatment
  
• Transplant evaluation or transplantation
  
• Complex medication regimens
  
• Significant discharge-planning needs
  
• Difficulty accessing appropriate healthcare services
  
• Potential social determinants of health affecting care
  
• Opportunities for provider or site-of-care navigation
  

Communicate pertinent information to Case Management and/or Care Navigation to support continuity and coordination of care.

DOCUMENTATION RESPONSIBILITIES

• Maintain accurate, complete, objective, and timely documentation of utilization-review activities.
  
• Document clinical information reviewed, applicable criteria, communications, requests for additional information, determinations, physician reviews, peer-to-peer discussions, and notifications.
  
• Maintain appropriate audit trails within the utilization-management system.
  
• Document rationale supporting nursing-level approvals and referrals for physician review.
  
• Ensure documentation supports internal quality reviews, regulatory requirements, employer-plan requirements, stop-loss needs, and audits.
  
• Complete documentation during scheduled working hours unless authorized overtime is required.
  

COMMUNICATION RESPONSIBILITIES

Communicate professionally and effectively with:

• Physicians and other healthcare providers
  
• Hospitals and healthcare facilities
  
• Members and authorized representatives
  
• Medical Director and physician reviewers
  
• Case Managers
  
• Care Navigators
  
• Claims personnel
  
• PBMs and specialty pharmacies
  
• Provider networks
  
• Stop-loss resources
  
• Internal leadership
  
• Compliance and other internal departments
  

Provide clear information regarding authorization requirements, requested clinical documentation, review status, and next steps while remaining within the scope and authority of the UR RN position.

REGULATORY & COMPLIANCE RESPONSIBILITIES

• Perform utilization-review activities in accordance with applicable federal and state requirements.
  
• Maintain compliance with HIPAA and organizational privacy and confidentiality policies.
  
• Follow applicable requirements for ERISA and non-ERISA health plans.
  
• Follow applicable state utilization-review requirements.
  
• Follow organizational procedures regarding adverse determinations, appeals, expedited reviews, peer-to-peer review, and notifications.
  
• Maintain appropriate separation between clinical medical-necessity review and benefit administration.
  
• Participate in utilization-management audits and quality reviews.
  
• Complete required compliance, privacy, clinical, and utilization-management education.
  

QUALITY & PERFORMANCE EXPECTATIONS

Performance may be evaluated based upon:

• Overall utilization-review productivity
  
• Routine and urgent review turnaround-time compliance
  
• Prospective, concurrent, and retrospective review timeliness
  
• Documentation accuracy and completeness
  
• Appropriate application of clinical criteria
  
• Appropriate escalation to Medical Director review
  
• Provider communication timeliness
  
• Authorization accuracy
  
• Quality-audit results
  
• Identification of high-risk/high-cost cases
  
• Appropriate Case Management and Care Navigation referrals
  
• Stop-loss notification compliance
  
• Attendance and reliability
  
• Compliance with departmental policies and procedures
  

Performance expectations will not require employees to perform uncompensated work outside recorded working hours.

NON-EXEMPT STATUS, WORK HOURS & TIMEKEEPING

This position is classified as non-exempt under the Fair Labor Standards Act (FLSA) and is eligible for overtime compensation in accordance with applicable federal and state law.

The employee is responsible for accurately recording all hours worked.

The UR RN is expected to:

• Accurately record beginning and ending work times and other timekeeping information required by company policy.
  
• Perform work only during scheduled or authorized working hours.
  
• Obtain advance approval from the appropriate supervisor before working overtime whenever practicable.
  
• Accurately report all overtime worked, including overtime that was not approved in advance.
  
• Refrain from performing work "off the clock."
  
• Record time spent completing documentation, reviewing medical records, responding to work-related communications, accessing work systems, or performing other job-related duties outside scheduled hours.
  
• Promptly notify the Supervisor/Manager if workload or urgent review requirements are likely to require overtime.
  
• Follow company policies regarding meal periods, rest periods, attendance, and timekeeping.
  

Employees will be compensated for all hours worked as required by law. Failure to obtain advance authorization for overtime may result in corrective action in accordance with company policy but will not result in withholding compensation for hours actually worked.

Because utilization review may involve time-sensitive or urgent requests, occasional overtime may be necessary based on business and member needs.

SCOPE OF AUTHORITY

The UR RN functions as a staff-level clinical reviewer and does not have supervisory authority unless specifically assigned.

Within established policies and delegated authority, the UR RN may:

• Approve services that satisfy applicable clinical criteria.
  
• Request additional clinical documentation.
  
• Communicate authorization status and clinical-information requirements.
  
• Refer cases for Medical Director review.
  
• Initiate appropriate Case Management or Care Navigation referrals.
  
• Identify potential plan exclusions, high-cost cases, and stop-loss concerns for escalation.
  

The UR RN may not independently issue an adverse medical-necessity determination when physician review is required.

The UR RN should not independently interpret ambiguous plan provisions or make final coverage determinations outside delegated authority.

Complex clinical, regulatory, benefit, provider, or operational issues should be escalated through the established departmental escalation structure.

Requirements

REQUIRED QUALIFICATIONS

• Current, unrestricted Registered Nurse (RN) license.
  
• Graduate of an accredited nursing program.
  
• Minimum of three years of clinical nursing experience preferred.
  
• Strong clinical assessment and critical-thinking skills.
  
• Ability to interpret medical records and clinical documentation.
  
• Knowledge of medical terminology, diagnoses, procedures, medications, and levels of care.
  
• Strong written and verbal communication skills.
  
• Strong organizational and time-management skills.
  
• Ability to manage multiple cases and competing priorities.
  
• Proficiency with electronic healthcare and business applications.
  

PREFERRED QUALIFICATIONS

• Bachelor of Science in Nursing (BSN).
  
• Previous utilization review/utilization management experience.
  
• Previous TPA, health plan, managed-care, insurance, or hospital utilization-management experience.
  
• Experience with self-funded employer health plans.
  
• Familiarity with ERISA.
  
• Experience with evidence-based medical-necessity criteria such as InterQual or MCG.
  
• Experience with prospective, concurrent, and retrospective review.
  
• Experience with appeals and peer-to-peer processes.
  
• Familiarity with stop-loss insurance and high-cost claimant identification.
  
• Experience with specialty medications and PBM coordination.
  
• CCM, ACM, CPUR, or other relevant professional certification preferred.
  

KNOWLEDGE, SKILLS & ABILITIES

• Strong clinical judgment within the RN scope of practice
  
• Critical thinking and analytical ability
  
• Attention to detail
  
• Effective organiz