Utilization Review Registered Nurse (UR RN)

ProviDRs Care•Wichita, KS

1d•Onsite

About The Position

The Utilization Review Registered Nurse (UR RN) performs clinical utilization-review activities for health plans administered by a Third-Party Administrator. The role evaluates healthcare service requests for medical necessity and compliance with applicable utilization-management criteria, plan provisions, organizational policies, and regulatory requirements. Reviews may be prospective, concurrent, or retrospective and use approved evidence-based criteria, plan documents, clinical policies, and available medical records. The UR RN collaborates with providers, facilities, the Medical Director, Case Management, Care Navigation, Claims, pharmacy benefit managers and specialty pharmacies, stop-loss resources, provider networks, and other stakeholders. Within delegated authority, the nurse may approve services meeting established criteria. Cases requiring physician judgment, including cases that may result in an adverse medical-necessity determination, are referred to the Medical Director or another appropriately qualified physician reviewer. The position is staff-level and has no supervisory authority unless specifically assigned. The role also supports prior authorization, inpatient continued-stay review, retrospective review, peer-to-peer coordination, appeals, plan-document review, specialty-medication coordination, high-cost case and stop-loss identification, and referrals to Case Management or Care Navigation. The UR RN maintains complete and timely documentation, communicates review requirements and outcomes, follows applicable privacy and regulatory requirements, and participates in audits and quality reviews. This is a full-time, hourly, non-exempt position requiring on-site work in Wichita, Kansas. The employee must accurately record all hours worked and may not work off the clock. Occasional overtime may be necessary for time-sensitive or urgent requests; overtime is compensable in accordance with applicable law.

Requirements

Current, unrestricted Registered Nurse (RN) license.
Graduate of an accredited nursing program.
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 skills.
Ability to work on-site in Wichita, Kansas.
Accurately record all hours worked and comply with applicable timekeeping and overtime procedures.

Nice To Haves

Minimum of three years of clinical nursing experience is preferred.

Responsibilities

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 documentation, evaluate relevant clinical information, and apply approved evidence-based criteria consistently.
Approve services that meet applicable clinical criteria and fall within delegated nursing authority.
Refer cases requiring physician-level judgment, including potential adverse medical-necessity determinations, to the Medical Director or another qualified physician reviewer.
Request missing or additional clinical documentation and document the rationale, criteria, communications, and review activities accurately.
Complete reviews within applicable regulatory, contractual, plan-specific, and departmental turnaround-time requirements.
Review prospective authorization requests, assess routine versus urgent processing, evaluate level of care and site of service, and identify clinically appropriate alternatives when applicable.
Conduct concurrent reviews of inpatient admissions and ongoing services; assess continued medical necessity, treatment progression, length of stay, discharge planning, and transition opportunities.
Refer members with complex needs or care-coordination needs to Case Management or Care Navigation and escalate potential reductions or terminations of authorized services according to established procedures.
Conduct retrospective reviews when appropriate, apply relevant clinical criteria and plan provisions, document findings, and refer cases requiring physician determination.
Prepare cases for Medical Director review, coordinate peer-to-peer discussions when appropriate, document physician decisions, process resulting actions, and ensure required notifications are initiated.
Assist with appeals by gathering records and prior determinations, routing appeals to qualified reviewers, monitoring timeframes, documenting outcomes, and processing modified or overturned determinations.
Review plan documents and identify prior-authorization requirements, potential exclusions, limitations, or coverage concerns; escalate unclear plan-language questions and avoid representing authorization as a guarantee of coverage or payment.
Review assigned specialty-medication requests, identify medical- versus pharmacy-benefit requirements, coordinate with PBMs and specialty pharmacies, and escalate complex coverage or sourcing questions.
Identify potentially high-cost or catastrophic cases and stop-loss concerns, notify appropriate parties, and assist with clinical documentation for stop-loss reporting when requested.
Maintain accurate, complete, objective, timely documentation and audit trails that support quality reviews, regulatory and employer-plan requirements, stop-loss needs, and audits.
Communicate professionally with providers, members and representatives, physician reviewers, internal teams, PBMs, pharmacies, and other stakeholders about authorization requirements, documentation, status, and next steps.
Follow applicable federal and state requirements, HIPAA and organizational privacy policies, ERISA and non-ERISA plan requirements, and procedures for adverse determinations, appeals, expedited reviews, peer-to-peer reviews, and notifications.
Participate in utilization-management audits and quality reviews and complete required compliance, privacy, clinical, and utilization-management education.
Accurately record all hours worked, work only during scheduled or authorized hours, obtain advance overtime approval when practicable, report all overtime, and promptly notify the supervisor or director when workload may require overtime.
Escalate complex clinical, regulatory, benefit, provider, or operational issues through the established departmental structure.