Utilisation Review Nurse

Utilisation Review Nurse Location: Cork Department: Medical Practice Team Type: Full-time, Permanent At Laya Healthcare, we’re committed to delivering exceptional, efficient, and clinically appropriate care for our members. Our Medical Practice Team plays a vital role in ensuring best‑in‑class clinical oversight, cost‑effective care pathways, and strong collaborative relationships with providers. As we continue to evolve and strengthen our medical governance and cost‑management capabilities, we are now hiring a Utilisation Review Nurse — a key role that ensures medical claims are managed in line with best practice, supports our internal teams with clinical insight, and drives high‑quality, efficient care for our members. This is a unique opportunity to contribute to smarter care delivery, promote evidence‑based practice, and influence clinical decision‑making across the Laya ecosystem. 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? At Laya, taking care of our people is just as important as taking care of our members. You’ll enjoy: 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 If you’re ready to help shape efficient, high‑quality care for Laya members, we’d love to hear from you. Apply today and help us deliver safer, smarter, and more effective care.