Utilization Review Registered Nurse (RN)
Location: Healthcare Facility – Artesia, New Mexico
Schedule: Monday–Friday
Employment Type: 13 - 26 week Contract - with options for direct hire by the client facility after
Work Arrangement: On-site; remote candidates who meet the requirements below may be considered
Position Summary
Advantage Staffing Services is seeking an experienced Utilization Review Registered Nurse for a healthcare facility in Artesia, New Mexico.
The Utilization Review RN will evaluate medical necessity, level of care, length of stay, resource utilization, and payer requirements while collaborating with physicians, nursing, case management, insurance representatives, and other members of the interdisciplinary team.
• Remote candidates may be considered if they hold an active New Mexico/Compact RN license and have a demonstrated history of successfully working from home. Remote candidates must be able to provide a professional reference from a previous supervisor who can verify their remote-work performance.
Key Responsibilities
• Conduct concurrent and retrospective reviews of inpatient and outpatient medical records.
• Evaluate medical necessity, admission status, continued stay, level of care, and appropriate use of healthcare resources.
• Apply recognized utilization review criteria, including InterQual, MCG, payer-specific guidelines, and applicable regulatory standards.
• Collaborate with physicians and clinical teams to obtain documentation supporting medical necessity and appropriate patient status.
• Identify cases requiring physician advisor review, secondary review, or escalation.
• Coordinate with case management, discharge planning, nursing, and other departments to support timely transitions of care.
• Complete payer notifications, clinical submissions, authorization requests, and continued-stay reviews within required timeframes.
• Monitor authorization status and follow up with payers to reduce avoidable denials and delays.
• Identify potential denials, documentation concerns, and utilization issues and communicate them promptly.
• Assist with denial prevention, reconsiderations, and appeals as assigned.
• Maintain accurate and timely documentation of all utilization review activities.
• Promote compliance with Medicare, Medicaid, commercial insurance, CMS, HIPAA, and facility policies.
• Participate in utilization management meetings, audits, interdisciplinary case discussions, and quality-improvement initiatives.
Required Qualifications
• Graduate of an accredited school of nursing.
• Current, unrestricted Registered Nurse license.
• Active New Mexico or Compact RN license.
• Previous hospital-based utilization review, utilization management, case management, or related experience.
• Knowledge of medical necessity review, patient-status determinations, payer authorization processes, and denial prevention.
• Familiarity with Medicare, Medicaid, commercial insurance, and applicable regulatory requirements.
• Strong clinical judgment, critical-thinking, documentation, and communication skills.
• Ability to work independently while collaborating effectively with an interdisciplinary team.
• Proficiency with electronic medical records, utilization management systems, and remote communication tools.
Additional Requirements for Remote Candidates
Remote candidates must:
• Hold an active, unrestricted RN license.
• Have a documented history of successfully working from home in utilization review, case management, or a closely related clinical role.
• Provide a professional reference from a previous supervisor who can verify successful remote-work performance, dependability, productivity, and communication.
• Maintain a private, secure, HIPAA-compliant workspace.
• Have reliable high-speed internet and telephone access.
• Demonstrate consistent availability, responsiveness, productivity, and time-management skills.
• Be available during the facility’s designated Monday–Friday working hours and for required meetings, training, and communication.
Qualifications
• Bachelor of Science in Nursing.
• Two or more years of acute-care nursing experience.
• Two or more years of hospital utilization review or utilization management experience.
• Experience using InterQual and/or MCG criteria.
• Experience with concurrent review, medical necessity determinations, payer authorizations, denial prevention, and appeals.
• Case Management or Utilization Review certification, such as ACM, CCM, or CPHQ.
• Experience working with rural or community hospitals.
Contract-to-Hire Opportunity
The selected candidate will work as an employee of Advantage Staffing Services throughout the contract period. Depending on performance, organizational needs, and mutual interest, the client facility may offer the candidate an opportunity to transition to direct employment.
Pay: $40.00 - $50.00 per hour
Benefits:
• Dental insurance
• Health insurance
• Life insurance
Experience:
• Utilization review: 2 years (Required)
• Registered Nurse: 1 year (Required)
License/Certification:
• RN License (Required)
Work Location: Remote