We are seeking an experienced Registered Nurse (RN) with multi-state experience to perform utilization reviews, medical necessity evaluations, demand package reviews, and provide litigation support including deposition and testimony services when needed. This position is RN only. Coding credentials are not required.
The ideal candidate must have experience reviewing medical records across multiple states and payer environments and be comfortable applying varying state Medicaid policies and commercial insurance guidelines.
Responsibilities:
• Conduct comprehensive utilization reviews to determine medical necessity and level of care
• Review medical records for documentation completeness and clinical appropriateness
• Evaluate inpatient, outpatient, and procedural services for compliance with payer guidelines
• Assist with preparation and review of demand packages for legal and insurance cases
• Analyze cases involving payer disputes, denials, and recoupments
• Prepare detailed, defensible written clinical review reports
• Provide affidavit support, deposition preparation, and testimony when required
• Interpret CMS guidelines, Medicare policies, and state-specific Medicaid requirements
• Identify clinical risk, quality-of-care concerns, and documentation deficiencies
Requirements
Required Qualifications:
• Active, unrestricted Registered Nurse (RN) license
• Minimum 5–7 years of clinical experience
• At least 3–5 years of utilization review, medical necessity review, or case review experience
• Demonstrated experience performing reviews in multiple states
• Strong knowledge of Medicare, Medicare Advantage, Medicaid, and commercial payer criteria
• Experience applying InterQual or MCG guidelines preferred
• Prior litigation support, deposition, or expert testimony experience strongly preferred
• Excellent written analytical and report-writing skills
• Ability to work independently and meet strict deadlines
Preferred Experience:
• Experience with inpatient and outpatient level-of-care determinations
• Appeals and denial review experience
• Experience supporting personal injury or civil litigation cases
• Background in case management or compliance review
This position may be contract, project-based, or part-time depending on qualifications. Candidates must be comfortable reviewing policies and clinical criteria across multiple jurisdictions.
