Utilization Review Nurse Practitioner

Overview

Responsibilities

• Evaluate inpatient and outpatient medical necessity based on clinical documentation and standardized criteria.
• Conduct concurrent reviews of hospital stays to determine the appropriateness of continued care.
• Collaborate with physicians and care teams to facilitate transitions to lower levels of care when medically stable.
• Issue approvals or refer complex cases to medical directors for secondary denial reviews.
• Document all clinical justifications and decisions in specialized utilization management software systems.
• Participate in internal audits and quality improvement initiatives to refine review processes.
• Communicate insurance coverage determinations and appeal rights to healthcare providers and facility staff.

Qualifications

• An advanced degree such as a Master of Science in Nursing or Doctor of Nursing Practice.
• Active licensure as a Registered Nurse and certification as a Nurse Practitioner in the practicing state.
• Extensive clinical experience in an acute care or specialized hospital setting.
• Proficiency in using clinical decision support tools and electronic health record systems.
• Strong knowledge of Medicare, Medicaid, and private insurance reimbursement policies.
• Demonstrated ability to apply evidence-based clinical criteria to diverse patient scenarios.

Nice to have

• Professional certification in Case Management or Healthcare Quality and Management.
• Prior experience specifically within a managed care or insurance environment.
• Experience with Milliman Care Guidelines or InterQual criteria systems.
• Strong analytical skills for interpreting population health data and trends.

Work environment

• Work is primarily performed in a remote home office or a corporate insurance office setting.
• Standard business hours are typical, with minimal requirements for weekend or holiday shifts.
• The role involves frequent use of teleconferencing tools and clinical databases.
• Interaction with other healthcare professionals is frequent but conducted via phone or digital communication.
• Physical demands are low, focusing on prolonged computer use and data entry.

Benefits & growth

• Compensation often includes a base salary supplemented by performance-based annual bonuses.
• Career progression typically leads to roles such as Director of Utilization Management or Medical Policy Lead.
• Employers frequently provide specialized training for coding, auditing, and regulatory compliance.
• Opportunities for professional development through nursing and case management associations are common.
• The role offers a high degree of work-life balance compared to direct clinical practice positions.