Clinical Review Rn Jobs (NOW HIRING)

Wichita, United States | Posted on 08/28/2026

• Salary Competitive exempt salary based on experience, education, and qualifications.
• State/Province Kansas
• Country United States

Department: Integrated Health Management
Reports To: Integrated Health Management Supervisor/Manager
Clinical Oversight: Medical Director, asapplicable
FLSA Status: Non-Exempt
Employment Status: Full-Time, Hourly

Salary: Based on previous work experience andyears of experience

POSITION SUMMARY

EMPLOYEE IS REQUIRED TO WORK ON-SITE

The Utilization Review Registered Nurse (UR RN) performs clinicalutilization review activities on behalf of health plans administered by theThird-Party Administrator (TPA). The UR RN evaluates requests for healthcareservices to determine whether requested services meet establishedmedical-necessity and utilization-management criteria and assists in ensuringservices are reviewed in accordance with applicable health plan provisions,organizational policies, and regulatory requirements.

The UR RN performs prospective, concurrent, and retrospective reviewsusing approved evidence-based clinical criteria, applicable plan documents,clinical policies, and available medical documentation.

The UR RN collaborates with healthcare providers, facilities, the MedicalDirector, Case Management, Care Navigation, Claims, pharmacy/PBM partners,stop-loss resources, provider networks, and other internal and externalstakeholders.

The UR RN may approve services that meet established criteria withindelegated authority. Cases that do not meet established criteria or may resultin an adverse medical-necessity determination are referred to the MedicalDirector or other appropriately qualified physician reviewer in accordance withorganizational policy and applicable requirements.

ESSENTIAL JOB RESPONSIBILITIES

• Perform prospective, concurrent,and retrospective utilization reviews.
• Review requests for inpatient andoutpatient services, procedures, surgeries, diagnostic testing, therapies,durable medical equipment, specialty medications, and other servicesrequiring utilization review or prior authorization.
• Review medical records andsupporting clinical documentation to determine whether sufficientinformation is available to complete the review.
• Apply approved evidence-basedclinical criteria consistently and appropriately.
• Evaluate diagnoses, treatmentplans, previous treatments, laboratory findings, imaging results,physician documentation, medication history, and other relevant clinicalinformation.
• Approve services that meetapplicable clinical criteria and fall within delegated nursing authority.
• Refer cases that do not meetestablished criteria, involve clinical uncertainty, or may result in anadverse medical-necessity determination to the Medical Director or otherqualified physician reviewer.
• Request additional clinicaldocumentation from providers when necessary.
• Accurately document the clinicalrationale and criteria used during the review.
• Complete reviews withinapplicable regulatory, contractual, plan-specific, and departmentalturnaround-time requirements.
  

Prospective Review / PriorAuthorization

• Review authorization requestssubmitted before services are rendered.
• Determine whether adequateclinical documentation has been submitted to support the requestedservice.
• Determine whether requestsqualify for routine or urgent/expedited processing according to applicabledefinitions.
• Review clinical justificationsubmitted for urgent requests.
• Apply applicablemedical-necessity criteria and utilization-management requirements.
• Evaluate requested level of care,site of service, frequency, duration, and other relevant clinical factors.
• Identify opportunities forclinically appropriate alternative sites of care when applicable.
• Request missing clinicaldocumentation promptly to avoid unnecessary delays.
• Refer cases requiringphysician-level clinical judgment to the Medical Director.
  

Concurrent Review

• Conduct concurrent review ofinpatient admissions and other ongoing services requiring continuedauthorization.
• Evaluate continued medicalnecessity and appropriateness of the current level of care.
• Obtain clinical updates fromhospitals, facilities, and providers.
• Monitor treatment progression,length of stay, discharge planning, and barriers to discharge.
• Identify opportunities fortransition to a lower level of care when clinically appropriate.
• Refer members with complexdischarge needs, significant medical conditions, or ongoingcare-coordination needs to Case Management.
• Escalate cases involvingpotential reduction or termination of previously authorized servicesaccording to established procedures.
• Complete continued-stay reviewswithin required timeframes.
  
• Conduct retrospective reviewswhen services were provided without prospective authorization or whenretrospective review is otherwise appropriate.
• Evaluate clinical documentationbased on the patient's clinical condition and information available at thetime services were rendered.
• Apply appropriate clinicalcriteria and plan provisions.
• Document findings andrecommendations.
• Refer cases requiringphysician-level determination to the Medical Director.
  

MEDICAL DIRECTOR & PEER-TO-PEERCOORDINATION

• Identify cases requiring MedicalDirector review.
• Prepare cases for physicianreview by organizing pertinent clinical information, applicable criteria,previous treatment, relevant plan provisions, and outstanding clinicalquestions.
• Refer potential medical-necessitydenials, modifications, or other adverse clinical determinations to theappropriate physician reviewer.
• Coordinate peer-to-peerdiscussions between treating providers and physician reviewers whenappropriate.
• Document Medical Directordecisions and peer-to-peer outcomes accurately.
• Process resulting authorizationsor other actions according to the physician's determination and establishedprocedures.
• Ensure required notifications areinitiated following physician review.
• Escalate complex or unusualclinical situations to the Supervisor, Manager, Director, and/or MedicalDirector as appropriate.
  

APPEALS

• Assist withutilization-management appeals as assigned.
• Gather medical records, previousdeterminations, clinical criteria, correspondence, and additionalinformation submitted in support of the appeal.
• Ensure appeals are routed toappropriately qualified reviewers.
• Maintain awareness of appealturnaround-time requirements and promptly escalate potential delays.
• Document appeal activities andoutcomes accurately.
• Process overturned or modifieddeterminations according to established procedures.
• Assist with member and providernotifications as appropriate.
  

BENEFIT & PLAN DOCUMENT REVIEW

• Review applicable Plan Documents,Summary Plan Descriptions, Adoption Agreements, amendments, schedules ofbenefits, exclusions, limitations, and utilization-management provisions.
• Identify whether requestedservices are subject to prior authorization or otherutilization-management requirements.
• Recognize the distinction betweena clinical medical-necessity determination and a benefit/coveragedetermination.
• Identify potential benefitexclusions, limitations, or coverage concerns during clinical review.
• Escalate unclear, conflicting, orcomplex plan-language questions to the appropriate Supervisor, Manager,Director, Claims, Compliance, or other designated resource.
• Avoid representing authorizationas a guarantee of coverage or payment.
• Follow organizationalrequirements regarding appropriate authorization disclaimers andmember/provider communications.
  
• Review specialty-medicationrequests when assigned and when the medication is subject toutilization-management review.
• Identify whether medications aresubject to medical-benefit or pharmacy-benefit requirements.
• Identify applicablespecialty-medication exclusions, prior authorization requirements,site-of-care requirements, or other plan provisions.
• Coordinate with PBMs, specialtypharmacies, Case Management, and other appropriate resources.
• Identify cases that may requireevaluation for alternative funding, manufacturer assistance, PAP/MAPprograms, biosimilars, specialty-pharmacy sourcing, or alternative sitesof care.
• Escalate complexspecialty-medication coverage or sourcing questions to appropriateleadership.
• Refer clinical questionsrequiring physician judgment to the Medical Director.
  

HIGH-COST CLAIM & STOP-LOSSIDENTIFICATION

The UR RN is expected to recognize utilization that may indicatesignificant health-plan exposure.

Responsibilities include:

• Identify potentially high-cost orcatastrophic cases during utilization review.
• Recognize diagnoses, treatments,admissions, specialty medications, transplant cases, neonatal cases,oncology treatment, dialysis, complex surgeries, and other services thatmay warrant additional review or notification.
• Notify Case Management andappropriate leadership according to established procedures.
• Assist with obtaining clinicaldocumentation needed for stop-loss reporting when requested.
• Follow departmental proceduresregarding high-cost claimant identification and stop-loss notification.
• Maintain appropriate separationbetween financial considerations and clinical medical-necessitydeterminations.
  

CASE MANAGEMENT & CARE NAVIGATIONREFERRALS

Identify and refer members who may benefit from additional support,including members experiencing:

• Complex or chronic medicalconditions
• Multiple hospitalizations oremergency department visits
• High-cost diagnoses or treatments
• Newly diagnosed seriousconditions
• Oncology treatment
• Difficulty accessing appropriatehealthcare services
• Potential social determinants ofhealth affecting care
• Opportunities for provider orsite-of-care navigation

Communicate pertinent information to Case Management and/or CareNavigation to support continuity and coordination of care.

DOCUMENTATION RESPONSIBILITIES

• Maintain accurate, complete,objective, and timely documentation of utilization-review activities.
• Document clinical informationreviewed, applicable criteria, communications, requests for additionalinformation, determinations, physician reviews, peer-to-peer discussions,and notifications.
• Maintain appropriate audit trailswithin the utilization-management system.
• Document rationale supportingnursing-level approvals and referrals for physician review.
• Ensure documentation supportsinternal quality reviews, regulatory requirements, employer-planrequirements, stop-loss needs, and audits.
• Complete documentation duringscheduled working hours unless authorized overtime is required.

COMMUNICATION RESPONSIBILITIES

Communicate professionally and effectively with:

• Physicians and other healthcareproviders
• Hospitals and healthcarefacilities
• Members and authorizedrepresentatives
• Medical Director and physicianreviewers
• Case Managers
• Care Navigators
• PBMs and specialty pharmacies
• Provider networks
• Stop-loss resources
• Internal leadership
• Compliance and other internaldepartments

Provide clear information regarding authorization requirements, requestedclinical documentation, review status, and next steps while remaining withinthe scope and authority of the UR RN position.

REGULATORY & COMPLIANCERESPONSIBILITIES

• Perform utilization-reviewactivities in accordance with applicable federal and state requirements.
• Maintain compliance with HIPAAand organizational privacy and confidentiality policies.
• Follow applicable requirementsfor ERISA and non-ERISA health plans.
• Follow applicable stateutilization-review requirements.
• Follow organizational proceduresregarding adverse determinations, appeals, expedited reviews, peer-to-peerreview, and notifications.
• Maintain appropriate separationbetween clinical medical-necessity review and benefit administration.
• Participate inutilization-management audits and quality reviews.
• Complete required compliance,privacy, clinical, and utilization-management education.
  

QUALITY & PERFORMANCE EXPECTATIONS

Performance may be evaluated based upon:

• Overall utilization-reviewproductivity
• Routine and urgent reviewturnaround-time compliance
• Prospective, concurrent, andretrospective review timeliness
• Documentation accuracy andcompleteness
• Appropriate application ofclinical criteria
• Appropriate escalation to MedicalDirector review
• Provider communication timeliness
• Authorization accuracy
• Quality-audit results
• Identification ofhigh-risk/high-cost cases
• Appropriate Case Management andCare Navigation referrals
• Stop-loss notification compliance
• Attendance and reliability
• Compliance with departmentalpolicies and procedures

Performance expectations will not require employees to performuncompensated work outside recorded working hours.

NON-EXEMPT STATUS, WORK HOURS &TIMEKEEPING

This position is classified as non-exempt under the Fair LaborStandards Act (FLSA) and is eligible for overtime compensation inaccordance with applicable federal and state law.

The employee is responsible for accurately recording all hours worked .

The UR RN is expected to:

• Accurately record beginning andending work times and other timekeeping information required by companypolicy.
• Perform work only duringscheduled or authorized working hours.
• Obtain advance approval from theapp