Utilisation Review Nurse

Utilisation Review Nurse

Location: Cork
Department: Medical Practice Team
Type: Full-time, Permanent

About the Role

The Utilisation Review Nurse will be responsible for assessing clinical claims, determining the appropriateness of care, and ensuring members receive treatment in the right setting, for the right duration, and in line with evidence based guidelines. You will collaborate closely with hospitals, consultants, and internal colleagues to promote efficient patient pathways, identify areas for improved practice, and provide clinical oversight that protects both care quality and cost efficiency.

This role requires strong clinical judgment, analytical ability, confident communication, and the capability to engage with healthcare professionals to support best practice across the continuum of care.

What You'll Be Doing Clinical Review & Care Pathway Management

• Review medical claims to verify that care was delivered in the appropriate clinical setting, with an appropriate length of stay and appropriate use of resources.
• Evaluate claims against medical guidelines, best practice standards, and benefit entitlement criteria.
• Establish, maintain, and continuously refine patient care pathways that support efficient, high quality care for members.

Provider Engagement & Collaboration

• Identify areas of inefficient or inappropriate practice and engage proactively with providers to implement improvements.
• Attend meetings with hospital personnel and consultants to educate, communicate outcomes, and influence adherence to best practice.
• Liaise with clinicians as required to discuss cases, clarify information, and support collaborative decision making.

Data Analysis & Reporting

• Assess clinical reports and claims activity to identify trends, risks, and opportunities for improvement.
• Update monthly utilisation review reports and highlight key findings.
• Collate and track savings achieved through utilisation review processes.
• Draft clinical letters, papers, and presentations as required.

Training, Governance & Continuous Improvement

• Deliver clinical training to new team members or non clinical colleagues where needed.
• Maintain awareness of emerging medical trends, care standards, and changes in the healthcare market.
• Contribute to process improvements and the overall development of the Medical Practice Team.
• Complete ad hoc tasks that support the smooth operation of the team.

About You Essential

• Registered General Nurse (RGN) qualification.
• Minimum of 3 years hands on clinical experience.
• Strong ability to analyse clinical information, interpret data, and make confident decisions.
• Excellent communication and presentation skills.
• Strong computer literacy and comfort working with clinical and operational systems.
• Ability to work under pressure, with high attention to detail and a proactive approach to decision making.

Desirable

• Experience engaging with clinicians or working within utilisation review, auditing, or clinical governance.
• Ability to challenge practice constructively and influence change across clinical environments.

Regulatory Requirements

As part of the Financial Regulator's Minimum Competency Requirements, you may be required to attain a Certified Insurance Practitioner accreditation or equivalent. If applicable, your Line Manager will confirm this and outline any associated CPD requirements.

Why Join Laya Healthcare?

• Health insurance from day one
• Hybrid working options
• Competitive salary and annual bonus
• Pension contributions
• Generous maternity, paternity & adoptive leave
• Continuous learning & career development
• Access to wellbeing programmes and onsite gym facilities (where applicable)
• A culture that values innovation, excellence, and personal growth