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 skilled Utilization Review Nurse to evaluate the appropriateness of patient care, optimize resource utilization, and ensure compliance with medical necessity criteria. This role involves managing commercial carrier reviews, preventing denials, ensuring revenue integrity, and fostering strong interdisciplinary collaboration within a dynamic healthcare environment.

Key Responsibilities

• Evaluate Care Appropriateness: Conduct medical necessity and level-of-care reviews (including admission, continued stay, and observation) using approved clinical criteria, whether working onsite or remotely.
• Optimize Resource Usage: Utilize proactive indicators (diagnoses, cost criteria, complications) to detect potential over- or under-utilization and address barriers to patient progress.
• Manage Carrier Reviews: Submit required clinical documentation to commercial carriers and the Financial Clearance Center (FCC) within one business day of admission.
• Coordinate Level-of-Care Decisions: Facilitate physician advisor referrals and second-level reviews; collaborate with providers and care managers to secure necessary clinical documentation and clarify status.
• Ensure Age-Specific Care: Assess patient data across all age groups and lifespans using clinical criteria, situational analysis, and departmental guidelines to prioritize reviews.
• Manage Appeals & Peer-to-Peer (P2P): Coordinate the P2P review process alongside physicians, the FCC, and Revenue Cycle teams, maintaining comprehensive documentation for appeal tracking.
• Prevent & Track Denials: Maintain thorough documentation to minimize denial rates, log status updates and overturned days, monitor readmissions, and report emerging denial trends.
• Execute Revenue Workflows: Manage assigned ConnectCare and ADT work queues to ensure seamless billing operations and compliance with CMS and revenue cycle goals.
• Resolve Billing Issues: Partner with Patient Access, Financial Counselors, the FCC, and the Business Office to resolve third-party payer billing concerns and communicate non-coverage determinations.
• Maintain Multidisciplinary Rapport: Partner closely with physicians, in-house care managers, nursing staff, and leadership to align on patient management and outcomes.
• Educate Stakeholders: Train hospital and medical staff on utilization review processes, regulatory updates, and payer requirements (e.g., MS-DRGs, POA).
• Adhere to Communication Protocols: Maintain professional, timely responsiveness across email, phone, and messaging tools according to FCC service-level agreements and guidelines.
• Maintain Professionalism: Exhibit a calm, constructive demeanor during stressful situations or conflict resolution.
• Support Departmental Operations: Assist peers during high-volume periods, cover coverage gaps, and accurately log statistical data within established deadlines.
• Drive Process Improvement: Actively contribute to departmental quality initiatives, committee meetings, task forces, and staff development programs.
• Ensure Compliance: Maintain clinical competency, professional development, and strict adherence to hospital policies, HIPAA, confidentiality standards, and patient rights.
• Flexibility: Perform additional job-related duties as assigned by leadership.

Qualifications

• Current unrestricted RN license required; RN compact license preferred.
• Clinical nursing experience in ICU, Emergency Department, or Operating Room.
• Current working knowledge of quality improvement processes.
• Strong clinical assessment, critical thinking, and problem-solving skills, with a proven ability to identify internal and community resources to drive optimal patient, quality, and financial outcomes.
• Exceptional written and verbal communication skills with a track record of negotiating effectively across physicians, payers, and multidisciplinary healthcare teams.
• Unwavering commitment to delivering exceptional customer service to all stakeholders.
• Ability to organize complex information, prioritize competing tasks, and execute effectively in a fast-paced environment.
• Highly resourceful and self-motivated with the ability to work independently.
• Inquisitive and open to leveraging modern technologies, including AI, to streamline workflows, eliminate operational friction, and enhance client/patient experiences.

Experience

• Clinical nursing experience in ICU, Emergency Department, or Operating Room.
• 5+ years of Utilization Review Nurse experience (preferred).
• Pediatric nursing experience (preferred).

Skills

• Current working knowledge of quality improvement processes.
• Strong clinical assessment, critical thinking, and problem-solving skills.
• Exceptional written and verbal communication and negotiation skills.
• Customer service focus.
• Excellent time management and prioritization abilities.
• Self-motivation and autonomous work capability.
• Openness to leveraging modern technologies, including AI, for workflow optimization.
• Interqual system experience (preferred).

Education

• Current unrestricted RN license required; RN compact license preferred.

Additional Requirements

• This is a remote role which requires access to high-speed internet.
• Candidates must be willing and able to travel and work on-site at corporate, client, or temporary locations as business needs dictate.
• Ability to work a 4x10 schedule, including every other weekend.
• Available shifts may include 10:00 a.m. - 8:00 p.m. or 12:00 p.m. - 10:00 p.m.

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.