US Registered Nurse – Utilization Review

About the role

The US Registered Nurse (USRN) will support clinical review and healthcare operations by evaluating medical records, validating clinical necessity, and ensuring compliance with payer and regulatory standards. This position focuses on accurate reimbursement outcomes through documentation review, utilization management, and collaborative case assessment.

Key responsibilities

• Conduct utilization review and evaluate medical necessity using established clinical criteria and guidelines.
• Review patient medical records to assess level of care, treatment plans, and services rendered.
• Ensure adherence to payer policies, CMS regulations, and industry standards.
• Perform prior authorization, concurrent review, and other utilization management activities as required.
• Support denial management by reviewing clinical cases and providing appeal‑related recommendations.
• Collaborate with providers, clinicians, and cross‑functional teams to resolve documentation gaps.
• Maintain productivity, quality, and performance metrics based on operational targets.
• Document review findings accurately in designated clinical systems and platforms.

Required profile

• Active, unrestricted US Registered Nurse (RN) license.
• Bachelor of Science in Nursing (BSN) preferred.
• 1–3 years bedside experience in ICU, ER, or Medical‑Surgical settings.
• At least 1 year experience in utilization review, case management, prior authorization, or clinical appeals.
• Strong knowledge of US healthcare system, clinical standards, and payer guidelines.
• Excellent clinical judgment, analytical thinking, and documentation skills.

Required skills

• InterQual
• MCG