Utilization Review Nurse

Health Care Administrators Association® (HCAA); Spokane (WA); On-site; USD 65,000 - 85,000; Full time

Job summary

Health Care Administrators Association® (HCAA) seeks a detail‑oriented reviewer to perform pre-service utilization reviews of medical records and treatment plans to determine medical necessity, appropriateness, and efficiency.

The role involves collaborating with care teams, applying clinical criteria and regulatory standards to support coverage decisions, and documenting decisions to support compliance and quality improvement goals.

Qualifications

• Must reside in Washington or Idaho within commuting distance of a medical center.
• Strong understanding of clinical guidelines and utilization review principles.
• Experience evaluating medical records and applying regulatory standards.

Responsibilities

• Review medical records and proposed care plans for medical necessity, appropriateness, and efficiency.
• Apply clinical criteria and regulatory standards to support coverage decisions.
• Coordinate and communicate with care teams and members about coverage options.
• Ensure decisions and documentation support compliance and quality improvement goals.

Skills

Clinical guidelines

Utilization review principles

Medical record evaluation

Communication skills

Collaboration

Job description

Role Summary: Perform pre-service utilization reviews of medical records and treatment plans to determine whether requested services are medically necessary, appropriate, and efficient.

Key Duties

• Review clinical documentation and proposed care plans for medical necessity, appropriateness, and efficiency.
• Apply clinical criteria and applicable regulatory/guideline standards to support coverage decisions.
• Coordinate and communicate with care teams and members to discuss coverage and available care options.
• Ensure decisions and documentation support compliance, quality improvement, and care management goals.

Qualifications & Requirements

• Must reside in Washington or Idaho within commuting distance of a medical center.
• Strong understanding of clinical guidelines, utilization review principles, and medical record evaluation.
• Excellent communication and collaboration skills to partner with care teams and members.
• Ability to work with compliance and quality improvement expectations.