RN Utilization Review Specialist

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

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