Utilization Review Nurse

We are seeking a DC licensed RN to perform utilization management reviews, ensuring healthcare services are medically necessary and meet quality standards. The role involves reviewing treatment plans, consulting with providers, documenting decisions, and supporting care management processes. Ideal candidates have clinical experience, utilization review expertise, and strong organizational and communication skills.

Responsibilities:

• Apply clinical review criteria, organizational policies, and guidelines to determine medical necessity of services
• Consult with physician/practitioner consultants when cases fall outside standard criteria
• Refer cases to appropriate clinicians as needed
• Review treatment plans and health records to ensure clinical appropriateness and quality outcomes
• Conduct admission and continued stay reviews using ASAM, InterQual, or other organizational policies
• Document utilization review decisions accurately in designated databases
• Communicate timelines and relevant information to clients, internal teams, and providers
• Provide guidance and serve as a resource for peers on utilization review processes
• Assist with appeal preparation and respond to medical affairs inquiries per organizational policy
• Monitor and provide oversight of non-clinical staff as appropriate, offering performance feedback to supervisors
• Perform quality assurance audits and other program support tasks as assigned
• Report HIPAA or PHI violations promptly in the appropriate system

Please note: Full time and Part time schedule available