Utilization Review Nurse

Utilization Review Nurse – Pediatrics & Young Adults

Location: Washington, DC (Hybrid: 4 Days Onsite, 1 Day Remote)

Schedule: Monday–Friday, 8:00 AM – 5:00 PM

Type: Full-Time

Overview:

A managed care organization is seeking an experienced Utilization Review (UR) Nurse to support preauthorization, initial, and concurrent reviews across a range of services including inpatient, behavioral health, rehab, and home health. This role focuses on medically complex pediatric and young adult populations (ages 0–25) and requires strong health plan UR experience.

Key Responsibilities:

• Review and authorize services using InterQual or Milliman criteria
• Manage a daily caseload of approximately 15 reviews
• Handle pediatric inpatient admissions and services such as long-term care, skilled nursing, and behavioral health

Must-Have Qualifications:

• Active RN license (DC)
• Utilization review experience in a health plan or insurance setting
• Proficient with InterQual or Milliman
• Familiarity with pediatric and young adult inpatient admissions

Preferred Experience:

• Experience in home health, rehab, long-term care, and behavioral analysis
• Experience with conditions such as cerebral palsy, genetic disorders, cancer, bipolar disorder, and substance use

This is a great opportunity for an experienced UR RN seeking meaningful work in a collaborative, supportive environment.