Utilization Review Nurse (RN) or Licensed Clinical Reviewer
Location: Columbia, SC
Job Type: Temp to Hire
Company: TRC Talent Solutions
Salary: $30.00 Per Hour
Category: Financial Services
Job Description Apply Now
The Utilization Review Nurse (RN) or Licensed Clinical Reviewer plays a vital role in ensuring that medical and behavioral health service requests align with established benefit coverage and medical necessity guidelines. This position is designed for licensed clinicians who possess a keen attention to detail, strong clinical judgment, and the ability to work efficiently in a remote environment. As part of a collaborative team, the Utilization Review Nurse (RN) or Licensed Clinical Reviewer leverages clinical expertise and contract knowledge to promote quality patient outcomes through the application of utilization management principles. This is an excellent opportunity for professionals seeking to utilize their nursing or clinical licensure in a position that emphasizes both independence and teamwork.
Utilization Review Nurse (RN) or Licensed Clinical Reviewer - SummaryThe Utilization Review Nurse (RN) or Licensed Clinical Reviewer is responsible for evaluating medical and behavioral health service requests to ensure they meet all necessary guidelines. The role combines clinical assessment skills with an understanding of managed care processes, including policy review and contract evaluation. Professionals in this position will manage caseloads, prioritize urgent reviews, and collaborate with medical directors as needed to support quality care and cost-effectiveness. The role requires a licensed clinician—either a Registered Nurse (RN), Licensed Master Social Worker (LMSW), Counselor, or Psychologist—who can independently manage remote work responsibilities after initial onsite training.
Duties & Responsibilities- Conduct medical and behavioral health utilization reviews and authorizations using clinical guidelines and benefit plan criteria.
- Evaluate documentation, prioritize cases based on urgency and due dates, and ensure timely completion of case reviews.
- Assess requests against policy provisions and member contracts to determine medical necessity and benefit coverage.
- Refer complex or ambiguous cases to the Medical Director for additional review and guidance.
- Communicate approval and denial decisions promptly and professionally with healthcare providers and internal teams.
- Maintain accurate and comprehensive documentation in compliance with regulatory standards and organizational policies.
- Participate in ongoing quality assurance activities and contribute to process improvement initiatives within the utilization review function.
- Collaborate effectively with case managers, providers, and interdisciplinary team members to ensure coordinated care for members.
- Competitive compensation commensurate with experience and licensure level.
- Comprehensive training provided, including one week of onsite orientation before transitioning to remote work.
- All necessary equipment provided for effective remote work performance.
- Access to professional development opportunities and ongoing support from a collaborative team.
- Opportunities to contribute to initiatives that enhance patient care and outcomes.
- Associate Degree in Nursing (ADN), or a Master’s degree in Social Work, Counseling, or Psychology from an accredited institution.
- Active, unrestricted license as a Registered Nurse (RN), Licensed Master Social Worker (LMSW), Counselor, or Psychologist.
- Minimum of two years of clinical experience in a relevant healthcare setting.
- Strong understanding of managed care principles, utilization management, and regulatory requirements.
- Demonstrated ability to work independently, prioritize tasks, and manage a diverse caseload efficiently in a remote setting.
- High level of comfort with technology, including electronic health record systems and remote communication platforms.
- Excellent interpersonal, verbal, and written communication skills.
- Licensed clinician with a background in utilization review, case management, or clinical assessment.
- Detail-oriented and organized, with strong critical thinking and problem-solving abilities.
- Adaptable to a fast-paced, remote work environment and able to maintain productivity independently.
- Team player who values collaboration and continuous improvement.
- Comfortable with navigating complex documentation and regulatory requirements.
- Effective communicator with providers, team members, and leadership.
- Remote work is available following successful completion of onsite training.
- Applicants must hold an active clinical license and meet all educational and experience requirements.
- This position is ideal for individuals seeking a balance between independent work and collaborative team culture.
- The organization is committed to diversity, equity, and inclusion in all hiring and employment practices.
- TRC Talent Solutions is proud to be an Equal Opportunity Employer (EOE). All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
If you are a licensed clinician seeking a meaningful career in utilization review, we encourage you to apply today by clicking the job application button and join a team dedicated to making a positive impact on patient care outcomes.