Utilization Review Nurse

Brundage Group; Pensacola (FL); On-site; USD 70,000 - 95,000; Full time

Job summary

Brundage Group is seeking an experienced Utilization Review Nurse to perform admission and continued stay reviews, ensuring medical necessity, payer requirements, regulatory standards, and quality patient care in a hospital setting.

The role collaborates with physicians, case management, revenue cycle, and care teams; requires extensive acute care nursing background, UR expertise (InterQual/MCG), and strong documentation and communication skills.

Qualifications

• Graduate of an accredited school of nursing.
• BSN preferred.
• Current, unrestricted RN license.
• Minimum five (5) years of acute care nursing experience in a hospital setting.
• Minimum two (2) years of recent hospital-based utilization review experience.
• Experience with acute admission reviews and continued stay reviews.
• Certified Case Manager (CCM), ACM, CMGT-BC, or CM Certifications preferred.

Responsibilities

• Perform hospital admission reviews to determine medical necessity and appropriate patient status.
• Conduct continued stay reviews using approved clinical criteria.
• Evaluate clinical documentation for accuracy and payer/regulatory compliance.
• Apply InterQual and/or MCG criteria.
• Communicate review findings to physicians, case management staff, and leadership.
• Collaborate with Physician Advisors on complex cases.
• Assist with denial prevention activities and accurate documentation.
• Performs other duties as assigned.

Skills

EHR proficiency

Case management systems

Communication skills

Independent worker

Education

RN license

BSN preferred

5+ years acute care

2+ years UR experience

UR certifications preferred

Tools

InterQual/MCG criteria

Job description

The Utilization Review Nurse is responsible for conducting admission and continued stay reviews to ensure appropriate utilization of hospital resources and compliance with medical necessity criteria, payer requirements, regulatory standards, and organizational policies. The Utilization Review Nurse works collaboratively with physicians, case managers, revenue cycle staff, and interdisciplinary care teams to facilitate appropriate patient status determinations and optimize reimbursement while supporting quality patient care. This position requires extensive acute care nursing experience and demonstrated expertise in utilization review within a hospital setting.

Duties and Responsibilities:

• Perform hospital admission reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient).
• Conduct continued stay reviews using approved clinical criteria and guidelines.
• Evaluate clinical documentation for accuracy, completeness, and compliance with payer and regulatory requirements.
• Apply evidence-based criteria such as InterQual® and/or MCG®.
• Communicate review findings and recommendations to physicians, case management staff, and leadership.
• Collaborate with Physician Advisors regarding complex cases or cases not supported by criteria.
• Assist with denial prevention activities and accurate documentation.
• Performs other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES: Abilities may be accessed through written, verbal, and other evaluation methods.

• Proficient in multiple Electronic Health Records and case management systems
• Strong communication skills. Communicates clearly and concisely, verbally and in writing
• Ability to thrive in a fast-paced environment and adapt to frequent changing business needs
• Ability to work independently, needing minimal supervision.

WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS: List preferred/required work experience, education, and certifications.

• Graduate of an accredited school of nursing
• Bachelor’s of Science in Nursing (BSN): preferred
• Current, unrestricted Registered Nurse (RN) license.
• Minimum five (5) years of acute care nursing experience in a hospital setting
• Minimum two (2) years of recent hospital-based utilization review experience
• Experience with acute admission reviews and continued stay reviews
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC): preferred.

WORK SCHEDULE REQUIREMENTS: Outlines FT scheduling, shift, and holiday obligations.

• Full-time employees may be scheduled for 8-, 10-, or 12-hour shifts based on operational needs and mutual scheduling agreements.
• Employees are expected to work every other weekend as required to support business operations.
• Three (3) of the six (6) company-recognized holidays will be assigned annually based on departmental and business needs.
• Work schedules are published one month in advance. Requests for vacation, time off, or schedule accommodations must be submitted at least thirty (30) days before the schedule is finalized (e.g., requests for the August schedule must be submitted by June 30).