Utilization Review Nurse

American Addiction Centers • Milwaukee, WI

1d • $36 - $53 • Onsite

About The Position

The Utilization Review Nurse is responsible for coordinating and performing utilization management (UM) activities to ensure appropriate resource use, regulatory compliance, and high-quality patient care. This role partners closely with physicians, interdisciplinary teams, and external stakeholders to support efficient care delivery, minimize delays, and optimize patient outcomes.

Requirements

• Active Registered Nurse (RN) license in the state of Wisconsin
• Bachelor’s Degree in Nursing (BSN)
• Typically requires 3 years of experience in clinical nursing, utilization review, and/or quality management
• Proficiency in Microsoft Office (Excel, Outlook, PowerPoint, Word) or similar tools
• Strong understanding of utilization review criteria and acute care patient needs
• Demonstrated competency in InterRater Reliability (IRR) with a score of 80% or higher
• Critical thinking skills to evaluate clinical scenarios and apply medical necessity criteria
• Excellent communication and interpersonal skills with the ability to collaborate with patients, families, physicians, and payers
• Conflict resolution skills with a focus on achieving positive, collaborative outcomes
• Ability to build and maintain strong professional relationships across disciplines
• Commitment to ongoing professional development and active participation in organizational initiatives

Responsibilities

• Conducts and documents utilization review activities in accordance with department and medical center standards, ensuring timely and accurate concurrent and retrospective reviews using established criteria.
• Collaborates effectively with the healthcare team, including medical staff, hospital departments, and ancillary services, to expedite care delivery and avoid delays.
• Participates in multidisciplinary teams to support care coordination, implement utilization management strategies, and report key activities.
• Partners with managers, physicians, medical directors, and treatment teams to address patient care issues and align with best practices.
• Refers cases to Physician Advisors as needed to ensure accurate patient status determination and compliance with regulatory guidelines.
• Maintains knowledge of healthcare regulations, reimbursement practices, and factors impacting length of stay and resource utilization.
• Communicates clinical updates to payers and external review organizations, manages denial activity, and identifies and resolves avoidable delays.
• Develops and sustains strong relationships with community agencies and external partners to support patient and family needs.
• Serves as a subject matter expert and educator for staff on utilization management, admission status, and regulatory requirements.
• Delivers age-appropriate care, demonstrating understanding of growth and development across the lifespan and applying this knowledge to patient assessment and care planning.

Benefits

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level