Utilization Review Nurse RN

Health Here; Baltimore (MD); On-site; USD 80,000 - 110,000; Full time

Job summary

Health Here, based in Baltimore, MD, is seeking an Utilization Review Nurse RN to perform concurrent and retrospective reviews ensuring medical necessity and appropriate care levels. The role involves applying criteria, documenting in EMR, and coordinating with care teams to facilitate safe, timely transitions.

The ideal candidate holds an RN license with strong knowledge of utilization review processes, regulatory requirements, and clinical documentation, plus excellent communication and

Qualifications

• RN license required.
• Strong knowledge of utilization review processes and regulatory requirements.
• Ability to interpret medical criteria and coordinate with multidisciplinary teams.

Responsibilities

• Conducts concurrent and retrospective reviews for medical necessity and appropriate care levels.
• Collaborates with physicians, care managers, and payers to secure authorizations and prevent denials.

Skills

RN license

Utilization review

Regulatory knowledge

Clinical documentation

InterQual criteria

Job description

Role: Utilization Review Nurse RN

Responsibilities: Conducts concurrent and retrospective reviews to ensure appropriate care levels, medical necessity, and compliance. Collaborates with physicians, care managers, and payers to secure authorizations, prevent denials, and facilitate safe, timely care transitions. Applies InterQual/MCG criteria, documents in EMR, identifies discharge barriers, and educates teams on utilization standards.

Qualifications & Skills: Nursing RN license, strong knowledge of utilization review processes, regulatory requirements, and clinical documentation. Excellent communication and collaboration skills, attention to detail, and ability to interpret medical criteria and coordinate with multidisciplinary teams.