We are seeking a Registered Nurse (RN) to join our Utilization Management team. In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care. You will collaborate closely with physicians, hospitals, and interdisciplinary teams to ensure members receive appropriate, cost-effective, and evidence-based care.
This position is ideal for an RN with a strong acute care background and proven experience in managed care and utilization management.
Key Responsibilities
- Utilization Reviews: Perform concurrent, prior authorization, and retrospective utilization reviews.
- Guideline Application: Evaluate medical necessity using InterQual, MCG, CMS, and LCD/NCD guidelines.
- Care Coordination: Coordinate discharge planning and seamless transitions of care with providers and healthcare facilities.
- Interdisciplinary Collaboration: Work alongside physicians, hospital staff, specialists, and internal care management teams.
- Documentation & Escalation: Request and review additional clinical documentation as needed; escalate complex medical necessity cases to the Medical Director.
- Provider Education: Educate providers on utilization management policies and review criteria.
- Compliance & Quality: Accurately document all reviews and decisions within medical management systems while identifying care gaps and supporting quality improvement initiatives.
Required Qualifications
- Licensure: Active Registered Nurse (RN) license (ability to obtain multi-state licensure if needed).
- Education: Graduate of an accredited School of Nursing.
- Clinical Experience: Minimum 4 years of clinical nursing experience.
- Managed Care Experience: Minimum 2 years of managed care or HMO experience (Medicare Advantage experience required).
- Core Expertise: Must have direct experience in:
- Concurrent Review & Inpatient Utilization Management
- Discharge Planning & Transitions of Care
- Utilizing InterQual, MCG, and CMS Guidelines
- Technical Skills: Proficiency with medical management software and Microsoft Office Suite.
- Soft Skills: Strong critical thinking, excellent communication, and exceptional organizational skills.
Preferred Qualifications
- Bachelor of Science in Nursing (BSN).
- Clinical background in Emergency Department (ER) or Intensive Care Unit (ICU).
- Case Management experience.
- Prior Utilization Management experience directly within a health plan or managed care organization.
- Experience working directly with hospitals, physicians, and provider networks.
What Will Make You Successful
- Strong clinical judgment and confidence in making accurate medical necessity determinations.
- Ability to comfortably navigate challenging conversations regarding levels of care.
- High organizational skills to manage multiple dynamic cases simultaneously in a fast-paced managed care environment.
- A detail-oriented mindset committed to high-quality patient outcomes.