You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.

Job Summary

Our client is seeking a Utilization Review Nurse. This role involves managing the full lifecycle of Independent Review Organization (IRO) cases, ensuring compliance with regulatory deadlines and maintaining accurate case tracking. The position requires collaboration with various stakeholders to support case progression and process optimization.

Key Responsibilities

• Manage the full lifecycle of IRO cases from intake through final case closure.
• Review incoming clinical documentation, verify completeness, and prepare concise case summaries for physician reviewers.
• Coordinate and route cases to the appropriate physician specialty while managing requests for additional medical records.
• Perform quality assurance (QA) on physician reports to ensure accuracy, clarity, completeness, and defensibility.
• Monitor regulatory deadlines, case status, and documentation to ensure timely, compliant case completion.
• Maintain accurate case tracking and documentation within internal systems and state IRO programs.
• Collaborate with physicians, clients, and internal teams to resolve documentation gaps and support case progression.
• Contribute to workflow improvements, new state program implementation, and process optimization as the organization grows.

Qualifications

• Active RN license and BSN required.
• Experience with Independent Review Organizations (IROs), or Utilization Review/Appeals within a Health Plan or TPA.
• Strong clinical documentation review, case summary writing, and quality assurance (QA) skills.
• Excellent written communication with exceptional attention to detail and ability to identify gaps in physician documentation.
• Ability to independently manage multiple cases while meeting regulatory turnaround times and deadlines.

Skills

• Technical skills: Experience with IROs, clinical documentation review, case summary writing, quality assurance.
• Soft skills: Excellent written communication, attention to detail, ability to manage multiple cases effectively.

Additional Requirements

M-F 8-5 schedule preferred CST/MST time zones for training; flexible with time zones. Some weekend coverage may be needed occasionally. Open to overtime if required and candidates are willing.

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.

Any required state or Joint Commission training is compensated at the state or local minimum wage rate.

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.