Utilization Review Registered Nurse

Join Public Consulting Group (PCG), a leading firm dedicated to improving public sector solutions and operations! Since 1986, we have been passionately transforming lives through our collaborations with health, education, and human services agencies. With a team of around 2,000 professionals across the U.S., we are committed to making a difference. If you're eager to create a positive impact, consider applying for our Utilization Review Registered Nurse position. As a Utilization Review Registered Nurse, you will utilize a medical management software system to provide essential funding sources for healthcare costs linked to birth-related neurological injuries. Key Responsibilities: Conduct thorough prior authorization, concurrent, and retrospective reviews. Utilize clinical documentation and established review criteria to evaluate qualifying healthcare costs. Precisely document all review determinations while maintaining accurate supporting records. Communicate effectively with providers and members within set timeframes. Identify and refer cases not meeting clinical criteria to the Case Management Supervisor. Report quality issues as they arise to the Case Management Supervisor. Share relevant information seamlessly with team members. Apply your knowledge of community resources and member benefit structures. Engage professionally with providers, vendors, and healthcare facilities. Recognize and appropriately escalate quality of care issues. Facilitate the Appeals and Grievances processes effectively. Assist members in coordinating necessary services as needed. Perform additional duties as assigned to support team objectives. Essential Skills: Outstanding verbal and written communication skills, especially over the phone. Adept at thriving in a fast-paced environment with excellent problem solving, critical thinking, and organizational skills. Proficient in managing multiple tasks with precision and attention to detail. Self-motivated and responsible, demonstrating a positive, team-oriented attitude. Able to navigate variable work environments with ease. Exhibit professionalism and competence in all client interactions. Provide exceptional customer service to all stakeholders. Strong computer skills with the ability to perform effective online research. Qualifications: Graduation from an accredited School of Nursing; an Associate Degree is required, while 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 within managed care, Medicaid, or utilization management settings. A current RN license is essential. Working Conditions: This position is remote. Join PCG in our mission to enhance public sector services for improved community health outcomes!

Created: 2026-03-05