Onsite Utilization Review RN: Impactful Patient Care

ProviDRs Care; Wichita (KS); On-site; USD 85,962,000 - 120,347,000; Full time

Job summary

ProviDRs Care is seeking a Utilization Review Registered Nurse (UR RN) in Wichita, Kansas. The UR RN will perform prospective, concurrent, and retrospective reviews to determine medical-necessity and utilization-management compliance, collaborating with physicians and health-plan staff.

This on-site role requires strong clinical judgment, experience with review criteria such as InterQual/MCG, and the ability to document rationale clearly while meeting turnaround times.

Qualifications

• Current, unrestricted RN license.
• Graduate of an accredited nursing program.
• Minimum of three years of clinical nursing experience preferred.
• 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 and time-management skills.
• Ability to manage multiple cases and competing priorities.
• Proficiency with electronic health care and business applications.

Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews.
• Review requests for inpatient and outpatient services, procedures, surgeries, diagnostic testing, therapies, durable medical equipment, and other services requiring utilization review or prior authorization.
• Review medical records and supporting clinical documentation to determine whether sufficient information is available to complete the review.
• Apply approved evidence-based clinical criteria consistently and appropriately.
• Evaluate diagnoses, treatment plans, previous treatments, laboratory findings, imaging results, physician documentation, medication history, and other relevant clinical information.
• Approve services that meet applicable clinical criteria and fall within delegated nursing authority.
• Refer cases that do not meet established criteria, involve clinical uncertainty, or may result in an adverse medical-necessity determination to the Medical Director or other qualified physician reviewer.
• Request additional clinical documentation from providers when necessary.
• Accurately document the clinical rationale and criteria used during the review.
• Complete reviews within applicable regulatory, contractual, plan-specific, and departmental turnaround-time requirements.

Skills

Clinical assessment

Medical record interpretation

Written and verbal communication

Time management

Case management

Electronic health records

Education

BSN (Preferred)

Graduated from accredited nursing program

Tools

EHR systems

Job description

ProviDRs Care is seeking a Utilization Review Registered Nurse (UR RN) in Wichita, Kansas. The UR RN will perform prospective, concurrent, and retrospective reviews to determine medical-necessity and utilization-management compliance, collaborating with physicians and health-plan staff.

This on-site role requires strong clinical judgment, experience with review criteria such as InterQual/MCG, and the ability to document rationale clearly while meeting turnaround times.