Job Summary The Utilization Review (UR) Nurse is responsible for analyzing medical records for medical‑legal reviews and producing high‑quality, professional executive summaries. These reports must follow client‑specific and evidence‑based guidelines, incorporating clear rationales for determining medical necessity. The role involves prospective, concurrent, and retrospective review of inpatient and outpatient treatment, certifying medical necessity, and recommending appropriate lengths of stay. Reports must be thorough, accurate, and tailored to the specific requirements of each case and client.
Essential Job Functions Analyze and interpret clinical documentation for medical‑legal reviews
Evaluate patient records to determine medical necessity and appropriateness of care using pre‑approved guidelines (e.g., ODG, MTUS, InterQual, MCG)
Draft clear, concise, and professional executive summaries that: Outline patient demographics and clinical course
Summarize and assess treatment plans and physician orders
Apply relevant evidence‑based criteria
Provide clear rationale and recommendations
Ensure all reports are grammatically correct, free of spelling errors, and professionally formatted
Dictate and finalize report content using designated systems
Collaborate with physicians and clinical staff to clarify documentation or resolve discrepancies
Amend reports as new clinical information becomes available
Perform moderate research on a case‑by‑case basis to support findings
Participate in interdisciplinary teams to support high‑quality patient care outcomes
Maintain a consistent caseload of 20‑40 cases per day post‑training
Achieve and maintain a Quality Assurance (QA) score of 97% or higher
Demonstrate consistent, reliable attendance and meet established deadlines
Perform additional duties as assigned
Requirements Knowledge and Abilities Requirements In‑depth understanding of anatomy, medical/surgical modalities, and imaging techniques
Strong knowledge of utilization review processes and criteria application
Excellent written communication skills, with a strong focus on grammar, spelling, clarity, and organization
Proven ability to analyze complex clinical information and apply critical thinking
Familiarity with medical necessity guidelines (ODG, MTUS, MCG, InterQual)
Ability to read and interpret clinical reports, technical documentation, and regulations
High proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
Strong attention to detail and ability to meet high standards for accuracy
Effective time management and multitasking skills in a deadline‑driven environment
Strong customer service orientation with the ability to communicate professionally with clients and providers
Ability to maintain confidentiality and demonstrate sound judgment
Ability to type a minimum of 45 WPM
Excellent verbal and written communication skills in English
Qualifications Active, unrestricted Registered Nurse (RN) license required
Minimum of 2–3 years of relevant clinical experience required
Prior experience in workers compensation, utilization review, case management, or medical‑legal review required
License and Certification Current RN licensure, without restrictions
Driving Essential No
Bonus Eligible Yes
Assessment May be required
Position Demands This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.
Equal Employment Opportunity (Our EEO Statement) The Company is a veteran‑owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non‑discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of discrimination should immediately report the concern to their Supervisor and Human Resources Department. Discrimination and harassment will not be tolerated.
We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.
Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All company team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.