Utilization Review Nurse

Tenet Healthcare

Utilization Review Nurse managing utilization decisions and healthcare coordination remotely for Conifer Health. Ensuring quality care and cost-effective measures in healthcare management.

Posted 6/24/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $64,168 - $96,262 per yearWebsite

About the role

Key responsibilities & impact

Collecting, analyzing, and evaluating clinical documentation received to determine appropriateness of clinical decisions
Adherence to regulatory and departmental timeframes for review of requests received
Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
Using an established set of criteria evaluates, applies and authorizes the medical necessity of inpatient and outpatient services. Referring to medical director when unable to approve a request.
Manages the provision of cost containment services by determining the medical necessity and appropriateness of setting and treatment, and channeling to network providers.
Uses clinical knowledge and evidence based criteria to determine the medical necessity of an inpatient admission, treatment plan and goals, identified gaps, risk for readmission or complications and any barriers to discharge
Collaborates with case / disease management departments and vendors to support client contractual agreements, SLA’s, SPD’s to ensure member receives quality care
Supports quality assurance initiatives, quality indicators and performance standards following standard documentation and ERISA / URAC guidelines

Requirements

What you’ll need

Bachelor degree in a health related field
Five (5) years of UM/CM experience preferred
Three to five (3-5) years of diverse clinical experience required
RN (Registered Nurse) license required in the state of residence

Benefits

Comp & perks

Medical, dental, vision, disability, life, and business travel insurance
Paid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.
401k with up to 6% employer match
10 paid holidays per year
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical documentation analysisutilization managementpre-certification reviewmedical necessity evaluationcost containment servicesevidence based criteria applicationquality assurance initiativesperformance standards adherencerisk assessmentdischarge planning

Soft Skills

collaborationcommunicationorganizational skillsproblem-solvingattention to detailcritical thinkinginterpersonal skillstime managementdecision makingleadership

Certifications

RN (Registered Nurse) license