Utilization Review Nurse
Join our team at Cobalt Benefits Group and start an exciting new career in employee benefits solutions. As a Utilization Review Nurse (UR Nurse), you’ll play an important role in helping us offer customized, self-funded insurance options to our clients and members.
The UR Nurse is responsible for reviewing clinical information to determine the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and levels of care in accordance with established criteria, payer guidelines, and organizational policies. This role involves evaluating healthcare services and facilities under the provisions of applicable health benefit plans to ensure quality and cost-effective patient care.
The UR Nurse collaborates closely with intake staff, physicians, specialists, case managers, and other members of the care team to facilitate timely and effective care authorizations, transitions, and utilization determinations. Strong communication, clinical judgment, and attention to detail are essential to ensure services meet both clinical standards and benefit requirements.
Responsibilities
- Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria.
- Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria.
- Request and evaluate clinical information needed to review requested services.
- Discuss cases and determinations with healthcare professionals and physician reviewers.
- Identify cases requiring intervention and collaborate with Case Managers as needed.
- Maintain appropriate and accurate documentation, ensuring compliance with audit standards.
- Participate in team meetings, educational sessions, and related activities.
- Review medical claims and pre-determinations for medical necessity and appropriateness.
- Identify opportunities for process improvement and enhance communication among departments.
- Consult with Physician Reviewers for complex or challenging cases.