Utilization Review Nurse

American Health Partners

Utilization Review Nurse assessing medical necessity and quality of healthcare services for American Health Plans. Collaborating with clinical teams to reduce hospitalizations and improve patient care.

Posted 7/24/2026full-timeFranklin • Tennessee • 🇺🇸 United StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization management, including assessing medical necessity and applying clinical review criteria. Proficient in Medicare regulations and clinical certification principles, with strong problem-solving and decision-making abilities.

Highest-signal resume keywords

Utilization Management ExperienceClinical Review Criteria ApplicationMedicare Regulations KnowledgeCertified Case Manager (CCM)Registered Nurse (RN) License

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity AssessmentClinical Data AnalysisCPT CodingICD-10 CodingHCPCS CodingInterqual UtilizationMCG UtilizationDecision-MakingProblem-Solving

Soft Skills

Customer Service

Certifications & Qualifications

Certified Case Manager (CCM)Registered Nurse (RN) License

Industry Keywords

Utilization ManagementURAC PrinciplesNCQA PrinciplesAccreditation StandardsRisk Management

About the role

Key responsibilities & impact

Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
Certify cases that meet clinical review criteria, guidelines and/or screens
Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
Refer cases to other professionals internally, including case management and medical consultation when indicated
Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
Other duties as assigned

Requirements

What you’ll need

At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG
Prefer clinical experience
Broad knowledge of Medicare regulations and guidance
Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
Excellent customer service experience
Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes
Proven ability to problem-solve and make solid decisions
Current Certified Case Manager (CCM) credential is a plus
Current, active and unrestricted Registered Nurse (RN) license

Benefits

Comp & perks

Affordable Medical/Dental/Vision insurance options
Generous paid time-off program and paid holidays for full time staff
TeleDoc 24/7/365 access to doctors
Optional short- and long-term disability plans
Employee Assistance Plan (EAP)
401K retirement accounts with company match
Employee Referral Bonus Program