CrawlJobs Logo
Dynamic Computing Services Logo Dynamic Computing Services · Nursing

Utilization Review Nurse

United States, Las Vegas Employment contract 40.00 - 63.00 USD / Hour · Job Posted April 23, 2026
Apply Position
Job Link Share

Job Description

We are seeking an Utilization Review Nurse for a full time permanent role onsite in Las Vegas, NV. Candidates must be legally authorized to work in the U.S. and able to go W2

Job Responsibility

  • Reviews patient admissions for appropriateness, efficiency of resource utilization and compliance with third party payer requirements
  • Duties include analyzing medical charts, determining whether care provided is within established parameters

Requirements

  • Graduation from an accredited school of nursing and five (5) years of acute hospital clinical nursing experience, one (1) year of which was in Utilization Management, Case Management, or Clinical Documentation Improvement
  • Valid license by the State of Nevada to practice as a Registered Nurse
  • Minimum three (3) years of Utilization Management experience
  • Minimum of three (3) year's experience with discharge planning in an acute care facility
  • Recent documented experience with InterQual, and ability to pass the InterQual exam
  • Recent documented experience with Milliman experience
  • Knowledge of: Interquel or Milliman utilization review criteria, Medicare/Medicaid guidelines, hospital policies and procedures
  • Joint Commission Accredited Health care Organizations standards, state statutes governing hospital services and health care, and other relevant regulations and standards
  • clinical medical and nursing procedures
  • disease processes
  • department and hospital safety practices and principles
  • patient rights
  • age specific patient care practices
  • infection control policies and practices
  • department and hospital emergency response policies and procedures
  • Skill in: Interpreting patient charts to determine whether care given is within best practice, appropriate for the diagnosis and properly documented
  • excellent ability to collaborate, co-ordinate and communicate findings
  • interpreting regulations and standards for others
  • writing reports, meeting minutes and other technical documents
  • analyzing statistical and other quantitative data
  • applying investigative and interviewing techniques
  • using a computer and a variety of software applications
  • communicating with a wide variety and establishing interpersonal relationships to interact effectively with co-workers, supervisor, staff in other work units and exchange or convey information
  • Physical Requirements and Working Conditions: Mobility to work in a typical office setting and use standard equipment, stamina to remain seated for extended periods of time, vision to read printed materials and a computer screen, and hearing and speech to communicate effectively in person and over the telephone
  • Strength and agility to exert up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects
  • May work shifts and weekends
Dynamic Computing Services - All Job Offers

Looking for more opportunities?

Search for other job offers that match your skills and interests.

Suggested Tags: Frontend Developer Secretary Talent Manager Salesforce Administrator Data Analyst
Similar Jobs for

Utilization Review Nurse

8 matching positions

Utilization Review Nurse LVN/LPN

Under the supervision of a registered nurse the Utilization Review Nurse will pr...
Location
Location
United States
Salary
Salary:
25.00 - 30.00 USD / Hour
personifyhealth.com Logo
Personify Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Current LVN license in the United States or U.S. territory
  • 1+ years of clinical experience required
  • Knowledge of medical claims and ICD-10, CPT, HCPCS coding
  • Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
  • Excellent verbal and written communication skills
  • Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Job Responsibility
Job Responsibility
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
  • all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity
  • and all post claim or post service reviews
  • Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants
  • Process appeals for non-certification of services
  • complete non-certification letters when appropriate
  • Review plan document for benefit determinations
  • attempt to redirect providers and patients to PPO providers
What we offer
What we offer
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions (yes, we use what we build)
  • Paid Time Off—rest and recharge time is non-negotiable
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture where diverse perspectives drive real impact on people's health
  • Fulltime
Read More
Arrow Right

Utilization Review Nurse - LVN/LPN

Under the supervision of a registered nurse the Utilization Review Nurse will pr...
Location
Location
United States
Salary
Salary:
25.00 - 30.00 USD / Hour
personifyhealth.com Logo
Personify Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Current LVN license in the United States or U.S. territory
  • 1+ years of clinical experience required
  • Knowledge of medical claims and ICD-10, CPT, HCPCS coding
  • Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
  • Excellent verbal and written communication skills
  • Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
Job Responsibility
Job Responsibility
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
  • all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity
  • and all post claim or post service reviews
  • Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants
  • Process appeals for non-certification of services
  • complete non-certification letters when appropriate
  • Review plan document for benefit determinations
  • attempt to redirect providers and patients to PPO providers
What we offer
What we offer
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions (yes, we use what we build)
  • Paid Time Off—rest and recharge time is non-negotiable
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture where diverse perspectives drive real impact on people's health
  • Fulltime
Read More
Arrow Right

Utilization Review Nurse RN (Part-Time)

We are seeking Utilization Review Nurse RN to join our team on a part-time basis...
Location
Location
United States
Salary
Salary:
30.00 - 38.00 USD / Hour
personifyhealth.com Logo
Personify Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Current RN license in the United States or U.S. territory
  • Associate’s degree or diploma (Nursing program) required
  • 1+ year clinical experience required
  • Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards
  • Ability to maintain regular, punctual attendance
  • Ability to sit for 6-8 hours
  • Constant use of computer keyboard and mouse
  • repetitive use of both hands
  • Occasional to frequent twisting of neck
  • occasional bending of neck and at waist
Job Responsibility
Job Responsibility
  • Provide professional assessment and review for the medical necessity of treatment requests and plans
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
  • inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity
  • and post claim or post service reviews. Staff are expected to cross train, and provide cross coverage as needed
  • Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants
  • Process appeals for non-certification of services, complete non-certification letters when appropriate
  • Review plan document for benefit determinations
  • attempt to redirect providers and patients to PPO providers
What we offer
What we offer
  • Part-time schedule designed around your availability and life priorities
  • Access to learning and development opportunities alongside full-time colleagues
  • Mentorship and skill-building that translates to career advancement
  • Competitive hourly compensation that values your expertise
  • Technology and equipment support to set you up for success
  • Parttime
Read More
Arrow Right

Utilization Review Nurse Manager

The Utilization Review Nurse Manager will oversee a team responsible for managin...
Location
Location
Philippines , Manila
Salary
Salary:
Not provided
nttdata.com Logo
NTT DATA
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Typically requires 5- 9 years relevant experience
  • Should be open to work in night shifts
  • Undergraduate degree or equivalent combination of education and work experience
  • Solid communication skills
  • Demonstrated client service skills and leadership capabilities
  • Good knowledge, understanding and application of project management principles and methodologies
  • Models excellent analytical / problem solving skills
  • Good client service skills and leadership capabilities
  • Solid analytical / problem solving skills
Job Responsibility
Job Responsibility
  • Provides front-line supervision to an operational team of 35 or more employees
  • Supervised team typically responsible for manging US healthcare Payer claims adjudication process
  • Assigns work to direct reports
  • Recommends and takes actions hiring, firing, promotion, and disciplinary recommendations
  • Supervises team ensuring the highest quality of service is provided to clients
  • Monitors performance of the team and reports results and issues to higher-level leadership
  • Assists team with escalated client or account issues
  • Manages hiring, staffing and maintaining a diverse and effective workforce
  • Interacts with clients and internal departments to resolve issues
  • Works with the team to complete assignments using established guidelines, policies and procedures
Read More
Arrow Right

Utilization Review Nurse - USRN

The Utilization Review Nurse role involves conducting clinical reviews to assess...
Location
Location
Philippines , Manila
Salary
Salary:
Not provided
nttdata.com Logo
NTT DATA
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • 1-3 years of experience in processing appeals or utilization management
  • RN - Registered Nurse - State required Licensure and/or Compact State Licensure
  • Knowledge of utilization management process
  • Knowledge of NCQA, Medicaid regulations
  • Good communication (Demonstrate strong reading comprehension and writing skills)
  • Able to work independently, strong analytic skills
  • Required shift timings - US daytime
Job Responsibility
Job Responsibility
  • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
  • Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
  • Communicates with providers, facilities and other departments regarding appeal requests
  • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
  • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests
  • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
  • Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards
  • Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals
  • Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation
  • Prepare case recommendations for medical review as necessary
Read More
Arrow Right

Utilization Review Nurse-LVN/LPN

Under the supervision of a registered nurse the Utilization Review Nurse will pr...
Location
Location
United States
Salary
Salary:
25.00 - 29.00 USD / Hour
personifyhealth.com Logo
Personify Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Current LVN license in the United States or U.S. territory
  • 1+ years of clinical experience
  • Knowledge of medical claims and ICD-10, CPT, HCPCS coding
  • Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook
  • Excellent verbal and written communication skills
  • Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
  • Must be able to remain in a stationary position 50% of the time
  • The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities
  • Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc.
  • Frequently positions self to maintain files in file cabinets
Job Responsibility
Job Responsibility
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
  • all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity
  • and all post claim or post service reviews
  • Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants
  • Process appeals for non-certification of services
  • complete non-certification letters when appropriate
  • Review plan document for benefit determinations
  • attempt to redirect providers and patients to PPO providers
What we offer
What we offer
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions (yes, we use what we build)
  • Paid Time Off—rest and recharge time is non-negotiable
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture where diverse perspectives drive real impact on people's health
  • Fulltime
Read More
Arrow Right

Utilization Review Nurse-RN

The Utilization Review Nurse will provide professional assessments and review fo...
Location
Location
United States
Salary
Salary:
30.00 - 38.00 USD / Hour
personifyhealth.com Logo
Personify Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Current RN license in the United States or U.S. territory
  • Associate’s degree or diploma (Nursing program) required
  • 1+ year clinical experience required
  • Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards
  • Ability to maintain regular, punctual attendance
  • Ability to sit for 6-8 hours
  • Constant use of computer keyboard and mouse
  • repetitive use of both hands
  • Occasional to frequent twisting of neck
  • occasional bending of neck and at waist
Job Responsibility
Job Responsibility
  • Provide professional assessment and review for the medical necessity of treatment requests and plans
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
  • inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity
  • and post claim or post service reviews
  • Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants
  • Process appeals for non-certification of services, complete non-certification letters when appropriate
  • Review plan document for benefit determinations
  • attempt to redirect providers and patients to PPO providers
What we offer
What we offer
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions
  • Paid Time Off
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture where diverse perspectives drive real impact on people's health
  • Fulltime
Read More
Arrow Right

Utilization Review Nurse-RN

The Utilization Review Nurse will provide professional assessments and review fo...
Location
Location
United States
Salary
Salary:
30.00 - 38.00 USD / Hour
personifyhealth.com Logo
Personify Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Current RN license in the United States or U.S. territory
  • Associate’s degree or diploma (Nursing program) required
  • 1+ year clinical experience required
  • Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards
  • Ability to maintain regular, punctual attendance
  • Ability to sit for 6-8 hours
  • Constant use of computer keyboard and mouse
  • repetitive use of both hands
  • Occasional to frequent twisting of neck
  • occasional bending of neck and at waist
Job Responsibility
Job Responsibility
  • Provide professional assessment and review for the medical necessity of treatment requests and plans
  • Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness
  • inpatient hospital stay including mental health, substance abuse, skilled nursing, and rehabilitation for medical necessity
  • and post claim or post service reviews
  • Work to the top of the RN license and ensure proper referral to medical director for denial authorizations through independent review organizations (IRO)
  • Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care
  • Refer requests that fall outside of established guidelines to advance review or senior care consultants
  • Process appeals for non-certification of services, complete non-certification letters when appropriate
  • Review plan document for benefit determinations
  • attempt to redirect providers and patients to PPO providers
What we offer
What we offer
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions
  • Paid Time Off
  • Mental health support, retirement planning, and financial protection
  • Professional development with clear career progression and learning budgets
  • Fulltime
Read More
Arrow Right