Utilization Review Nurse - RN (WHWC)

Role Overview & Responsibilities

Position Summary

The Utilization Review Nurse is a vital member of the care coordination team, responsible for reviewing patient records, assessing the necessity and appropriateness of proposed treatments, collaborating with healthcare providers, and facilitating communication across multidisciplinary teams to ensure continuity of care.

This role requires strong clinical knowledge, excellent communication and organizational skills, and the ability to manage multiple referrals in a fast-paced environment.

Scope and Impact


* Supports care coordination across MHM clinics and contracted specialty providers.


* Influences patient access, quality of care, and timeliness of services through referral review, pre-authorization, and diagnostic coordination.


* May manage a high-volume caseload of concurrent referrals and authorizations.

Decision-Making Authority


* Exercises independent clinical judgment to determine medical necessity and level of care based on referral criteria and documentation.


* Escalates complex cases and exceptions per policy and collaborates with providers for final clinical decisions.

Interactions / Working Relationships


* Daily coordination with primary care providers, contracted specialty providers, and physician office staff.


* Regular collaboration with Care Coordination RN/LVN/MA, social services, and multidisciplinary teams.


* Frequent communication with Patient Referral Coordinators regarding orders, pre-authorizations, scheduling, and follow-up.

Essential Duties and Responsibilities


* Review incoming clinical documentation and referral requests to determine medical necessity and appropriate level of care.

(25%)


* Enter, update, and maintain accurate clinical information in medical management and EHR systems.

(10%)


* Process requests and authorizations within required timelines and payer or organizational guidelines.

(15%)


* Coordinate and transmit diagnostic orders to Patient Referral Coordinators for labs, imaging, and procedures at MHS facilities.

(10%)


* Prepare and submit pre-authorization requests on behalf of contracted specialty providers for services and medications.

(10%)


* Communicate effectively with MHM clinics and specialty offices regarding acceptance, scheduling, and follow-up care.

(10%)


* Collaborate with multidisciplinary teams to support the care model and patient-centered medical home principles.

(10%)


* Educate patients and families regarding care plans, diagnostics, and next steps as appropriate.

(5%)


* Document tracked outcomes using appropriate terminology and standard abbreviations; maintain accurate referral records.

(3%)


* Adhere to HIPAA, apply medical terminology accurately, and perform other duties as assigned.

(2%)

Supervisory or Leadership Responsibilities

This position does not supervise others.Qualifications

Minimum Qualifications (Required)


* Education: G...