Position Title: Utilization Review Nurse – Post-Acute Care Work Location: Remote Assignment Duration: 3 Months Work Arrangement: Remote within a managed care setting Work Schedule: May require occasional weekend or holiday coverage
Location restriction: Please only submit candidates from the following states: Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin Position Summary:
The Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of post-acute care services, including inpatient rehabilitation, skilled nursing facility and long-term acute care levels of care. This role ensures alignment with evidence-based guidelines, regulatory requirements and organizational policies while promoting optimal patient outcomes and cost-effective care.
Key Responsibilities:
Conduct utilization review for post-acute care services, including o Inpatient Rehabilitation Facilities (IRF)/Acute Rehab o Skilled Nursing Facilities (SNF)/Subacute Nursing Facilities o Long-Term Acute Care Hospitals (LTAC)
Review clinical documentation to determine medical necessity, level of care, and length of stay using approved criteria (e.g., InterQual and internal medical policies).
Perform: o Prior authorization reviews o Concurrent reviews o Retrospective reviews as needed
Collaborate with providers, case managers, and interdisciplinary teams to ensure appropriate care planning and transitions of care.
Communicate determinations (approvals, denials, modifications) clearly and timely to providers and stakeholders.
Identify cases that require escalation to Medical Directors and participate in discussions with Medical Director when appropriate.
Monitor ongoing cases for continued stay criteria and discharge readiness.
Ensure compliance with: o CMS guidelines o State and federal regulations o NCQA Accreditation standards
Document all review activities accurately in the utilization management system.
Participate in quality improvement initiatives and audits related to utilization management and post-acute care.
Qualification & Experience:
Education: o Active, unrestricted Registered Nurse (RN) license o Bachelor of Science in Nursing (BSN) preferred
Experience: o 3–5 years of clinical nursing experience required o Previous experience in a managed care organization required o Prior experience in utilization review, case management, or discharge planning preferred o Strong background in post-acute care settings (IRF, SNF, LTAC) highly desirable
Knowledge & Skills: o Familiarity with utilization review criteria (InterQual) o Knowledge of post-acute levels of care and admission criteria o Understanding of managed care principles and reimbursement models o Strong clinical assessment and critical thinking skills o Excellent communication and negotiation abilities o Proficiency in electronic medical records and UM systems
For information on benefits, equal opportunity employment, and location-specific applicant notices, click here
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $48.00/hr - $52.00/hr.
