RN - Utilization Review

Orison-Solutions-LLC; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

Orison-Solutions-LLC is seeking an experienced Registered Nurse (RN) - Utilization Review to assess medical necessity, appropriateness, and level of care for patients. The RN will review clinical documentation, apply established guidelines, and collaborate with physicians, case managers, health plans, and other healthcare professionals to ensure appropriate utilization of services.

The role requires active NY RN licensure, evidence-based guideline application, and at least 1 year of non-acute

Qualifications

• Active New York State RN license.
• Primary Source Verification completed.
• AHA BLS certification.
• At least 1 year of non-acute utilization review experience.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews.
• Evaluate medical necessity and level of care.
• Review records to ensure criteria are met.
• Apply guidelines (InterQual, MCG, CMS) as applicable.
• Communicate with physicians and providers about decisions.
• Assist with authorizations, denials, and appeals when needed.
• Maintain HIPAA compliance and protect patient confidentiality.

Skills

Utilization review

Education

New York State RN License

Primary Source Verification

AHA BLS

Job description

We are seeking an experienced Registered Nurse (RN) - Utilization Review to evaluate the medical necessity, appropriateness, and level of care for patients. The RN will review clinical documentation, apply established medical guidelines, and collaborate with physicians, case managers, health plans, and other healthcare professionals to ensure appropriate utilization of healthcare services.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews of patient records.
• Evaluate medical necessity and appropriateness of admissions, continued stays, procedures, and levels of care.
• Review clinical documentation and medical records to determine whether services meet established criteria.
• Apply evidence-based guidelines such as InterQual, MCG, CMS, and payer-specific criteria, as applicable.
• Communicate with physicians and other healthcare providers regarding clinical information and utilization decisions.
• Identify opportunities for appropriate resource utilization and cost-effective care.
• Collaborate with Case Management, Quality Management, Medical Directors, and insurance companies.
• Prepare and maintain accurate documentation of utilization review activities.
• Escalate cases to the appropriate physician advisor or Medical Director when criteria are not met or additional clinical review is required.
• Assist with authorization requests, denials, appeals, and reconsiderations when applicable.
• Ensure compliance with applicable healthcare regulations, organizational policies, and payer requirements.
• Maintain confidentiality of patient information in accordance with HIPAA regulations.

Required Certifications & Licensure

• New York State RN License.
• Primary Source Verification.
• AHA BLS.

Required Skills & Experience

• One (1) year of non-acute utilization review experience.