Registered Nurse - Utilization Review

Registered Nurse-Utilization Review

Job ID #1965409

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About this Role

As a Utilization Review Registered Nurse (RN) supporting a health plan or insurance organization, you will use your clinical expertise to evaluate the medical necessity, appropriateness, and efficiency of healthcare services requested by providers. You'll serve as a critical liaison between healthcare providers and the health plan-helping to ensure that members receive the right care, in the right setting, at the right time. This role is a blend of clinical decision-making and administrative coordination, requiring strong communication skills and a solid understanding of medical guidelines and coverage policies.

Job details

Pay Rate: $51.00 / hour

Location: Bakersfield, California

Profession: Registered Nurse

Facility Type: ???

Specialty: Utilization Review

Division: MedFi

Start Date: 02/17/2026

Responsibilities

• Review prior authorization requests and clinical documentation to determine medical necessity and appropriate level of care.
• Apply utilization review criteria (e.g., InterQual, MCG) and plan policies to support coverage decisions.
• Collaborate with physicians, providers, and internal teams to obtain necessary documentation and clarify clinical details.
• Communicate determinations clearly and professionally to providers and members.
• Identify and escalate cases requiring physician review or medical director input.
• Document all review activities and decisions in accordance with regulatory and organizational standards.
• Participate in quality initiatives, audits, and policy updates to support continuous improvement.

Required Qualifications

• Current RN license
• BLS (other certifications as required by facility)
• Two years of recent Utilization Review RN experience
• Strong communication and adaptability skills