Job Description Job Description Utilization Review Nurse / Clinical Medical Necessity Reviewer (RN)
(MUST LIVE IN NY, CT, or NJ w/ NY RN License)
Department: Utilization Management / Clinical Operations
Employment Type: Full-Time
Position Overview
We are seeking an experienced and detail-oriented Utilization Review Nurse (RN) to join our Utilization Management team. In this role, you will perform clinical medical necessity reviews across inpatient and outpatient care settings, ensuring that our members receive the right level of care at the right time in compliance with state, federal, and regulatory standards.
Working closely with treating physicians, peer review panels, and medical directors, you will apply evidence-based clinical criteria to make fair, objective coverage determinations, coordinate care transitions, and minimize care delays.
Key Responsibilities
Clinical Medical Necessity Reviews: Conduct prospective, concurrent, and retrospective clinical reviews across inpatient and outpatient services to evaluate medical necessity, appropriateness of care, and compliance with regulatory mandates.
Evidence-Based Guidelines: Consistently apply established clinical criteria, including InterQual Care Guidelines, to determine healthcare coverage, benefit limits, and medical appropriateness.
Provider & Peer Collaboration: Partner closely with treating and referring clinicians to gather clinical documentation, clarify treatment plans, explain review processes, and consult with physician peer reviewers and Medical Directors on complex determinations.
Decision Communication: Clearly and professionally communicate coverage decisions and rationale to patients, ordering clinicians, and healthcare facilities.
Level of Care Matching & Intervention: Identify appropriate levels of care and resource utilization; proactively intervene to prevent administrative delays, reduce readmissions, and minimize avoidable denials.
Appeals & Adverse Determinations: Monitor and support internal and external appeals; ensure adverse determination language complies with clinical and legal standards, and assist with external appeal reviews as needed.
Documentation & Quality Improvement: Maintain rigorous, auditable documentation in compliance with VCMAX policies, while actively participating in departmental quality improvement (QI) and audit initiatives.
Inter-Rater Reliability (IRR): Maintain high standards of review consistency and objectivity by participating regularly in IRR testing and Utilization Management competency assessments.
Required Qualifications
Experience: Minimum of 2 years of direct utilization review/utilization management experience within a Managed Care Organization (MCO) or Health Plan.
Education: Bachelor of Science in Nursing (BSN) from an accredited program.
Licensure: Active, unencumbered Registered Nurse (RN) license; must possess or obtain a New York State (NYS) RN license within 3 months of hire.
Clinical Criteria: Demonstrated proficiency using InterQual Care Guidelines and comparable evidence-based criteria sets.
Regulatory Acumen: Solid understanding of Medicare and/or Medicaid guidelines, coverage determinations, and compliance frameworks.
Technical Skills: Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and electronic medical record (EMR)/utilization review management platforms.
Preferred Qualifications
Master's degree in Nursing (MSN), Healthcare Administration, or a related field.
Professional certifications such as Certified Case Manager (CCM) or URAC-recognized credentials.
1+ year of recent experience in hospital discharge planning.
1+ year of recent experience handling precertification/prior authorizations.
For California Applicants:
We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
Company Description
Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine.
Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?
Company Description Here at Medix, we are dedicated to providing workforce solutions to clients throughout multiple industries. We have been named among the Best and Brightest Companies to Work For in the Nation for two consecutive years. Medix has also been ranked as one of the fastest growing companies by Inc. Magazine. Our commitment to our core purpose of positively impacting 20,000 lives affects not only the way we interact with our clients and talent, but also with our co-workers! The goal is lofty, but it is made attainable through the hard work and dedication of our teams and their willingness to lock arms together. Are you ready to lock arms with us?
