Utilization Review Nurse
HybridBradenton, Florida, United States
Job Summary
Review medical treatment requests and supporting clinical documentation for adherence to state guidelines and utilization review requirements. Apply clinical knowledge to determine whether treatment requests can be authorized at the nurse level or refer cases requiring physician review. Evaluate medical records to support timely decisions while completing required documentation and administrative processing within state-mandated and URAC turnaround requirements. Collaborate with physicians, claims professionals, and internal team members to facilitate the review process and maintain confidentiality of medical information in accordance with HIPAA standards. Manage assigned reviews while maintaining current clinical knowledge relevant to utilization review and workers' compensation. This hybrid position requires two days in the office and three days remote, with flexibility to work later hours to support business needs across time zones.
Required Qualifications
- Active LPN license
- Active multistate/compact nursing license
- Strong clinical nursing experience with the ability to review medical records and evaluate treatment requests
- Ability to interpret medical terminology, treatment plans, and clinical documentation
- Ability to apply established clinical guidelines and determine when requests require physician review
- Flexibility to periodically work later hours to support business needs across multiple time zones
- Strong organizational skills with the ability to prioritize a high volume of time-sensitive reviews
- Strong written and verbal communication skills
- Proficiency with Microsoft Office applications and ability to learn new clinical and claims systems
- Active Licensed Practical Nurse (LPN) license
- Active multistate/compact nursing license
- Comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership
Desired Qualifications
- Experience in utilization review or case management
- Clinical experience involving orthopedic or neurological conditions
- Workers' compensation utilization review experience
- Utilization review or case management experience
- Clinical experience involving orthopedic or neurological conditions
- Additional utilization review, case management, workers' compensation, or related professional certifications
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