Nurse for Utilization Review

Join Public Consulting Group (PCG), a top-tier firm specializing in public sector solutions and operations improvement! Since 1986, we have been dedicated to transforming lives through our collaborative efforts with health, education, and human services agencies. With a workforce of around 2,000 professionals across the U.S., we are committed to delivering impactful solutions. If you're ready to make a difference, consider applying for the position of Utilization Review Nurse. As a Utilization Review Nurse, you will leverage a medical management software system daily to help provide a funding source for health care costs related to birth-related neurological injuries. Key Responsibilities: Conduct prior authorization, concurrent, and retrospective reviews. Utilize clinical documentation and review criteria to assess qualifying health care costs. Document all review determinations and maintain supporting records accurately. Communicate with providers and members within established timeframes. Identify cases not meeting clinical criteria and refer to the Case Management Supervisor. Report quality issues to the Case Management Supervisor. Share information effectively with team members. Apply knowledge of community resources and member benefit structures. Engage professionally with providers, vendors, and facilities. Recognize and appropriately escalate quality of care issues. Facilitate the Appeals and Grievances processes. Assist members with coordinating services as needed. Perform other duties as assigned. Essential Skills: Strong verbal and written communication skills, particularly over the phone. Ability to thrive in a fast-paced environment, showcasing excellent problem solving, critical thinking, and organizational capabilities. Proficient at managing multiple tasks with precision and attention to detail. Self-motivated and responsible, with a positive team-oriented attitude. Adept at navigating variable work environments. Exhibit professionalism and competence in client interactions. Provide exceptional customer service. Strong computer skills with the ability to conduct effective online research. Qualifications: Graduation from an accredited School of Nursing; an Associate Degree is required, a Bachelor's Degree is preferred. A minimum of 2 years of direct clinical nursing experience. At least 2 years of experience in medical management activities in managed care, Medicaid, or utilization management settings. Current RN license is mandatory. Working Conditions: Position is remote. Join us at PCG and be part of our mission to improve public sector services for better community health outcomes!

Created: 2026-03-04