Utilization Management Nurse

Position Summary

The Utilization Management (UM) Registered Nurse (RN) is responsible for ensuring the appropriate utilization of healthcare services, promoting cost-effective care, and ensuring compliance with healthcare regulations and organizational policies. This role involves evaluating medical records, coordinating with healthcare providers, and making determinations about medical necessity, treatment appropriateness, and level of care. The UM RN ensures the care delivery supports the member in achieving optimal health outcomes by coordinating appropriate services, monitoring progress, and advocating for the member’s needs throughout their healthcare journey.

Key Responsibilities

• Utilization Review
• Conduct initial pre-authorization, concurrent, and retrospective reviews for medical necessity, appropriateness, and efficiency of services for services provided across various settings, including acute care, skilled nursing facilities, outpatient clinics, and home health.
• Use industry-standard guidelines (e.g., Milliman Care Guidelines [MCG], InterQual) to assess the necessity and duration of services.
• Make recommendations regarding care delivery to align with medical necessity and insurance requirements.
• Make determinations on service approvals or escalations to Medical Directors for review.
• Care Coordination
• Evaluate medical records, physician orders, and care plans to ensure treatments align with evidence-based guidelines.
• Identify and recommend the most appropriate care settings (e.g., inpatient, outpatient, observation) based on clinical findings and insurance criteria.
• Collaborate with providers, case managers, and members to ensure seamless transitions of care and develop discharge plans that ensure continuity of care and prevent readmissions.
• Facilitate referrals for specialized care, diagnostic services, or alternative treatment options when necessary.
• Provide education to members and providers about plan benefits and covered services.
• Insurance Authorization and Appeals
• Analyze and evaluate medical records, treatment plans, and physician recommendations to determine if a procedure, medication, or service meets insurance criteria.
• Collaborate with physicians, healthcare providers, and insurance companies to gather necessary information and clarify treatment plans.
• Ensure that requested services align with payer policies, clinical guidelines, and evidence-based practices.
• Review insurance denial letters to understand the reason for denial and assess whether the treatment is medically necessary.
• Prepare and present appeals for denied services by collecting and organizing medical records, provider notes, and other documents to support appeal cases.
• Draft detailed, clinically supported appeal letters to insurance companies, clearly explaining the necessity of the denied service.
• Assists with peer-to-peer reviews to support authorization requests.
• Documentation and Reporting
• Maintain accurate and detailed records of all reviews, communications, and decisions in compliance with regulatory standards and internal policies.
• Monitor and report trends in care delivery, authorization denials, and utilization patterns to identify opportunities for process improvement.
• Assist with the preparation of reports and summaries for clients and carriers.
• Assist in the preparation of reporting for stop-loss renewal and work with stop-loss carriers to answer their questions.
• Regulatory Compliance
• Ensure adherence to state, federal, and accreditation requirements (e.g., URAC, NCQA).
• Stay updated on industry standards, clinical guidelines, and health plan policies.
• Participate in continuing education programs related to utilization management, payer regulations, and clinical guidelines.
• Stay informed about changes in diagnostic and procedural coding standards, such as updates to ICD-10, CPT, and HCPCS codes.
• Team Collaboration
• Work closely with the Medical Management team to optimize processes and improve outcomes.
• Participate in interdisciplinary meetings, training sessions, and policy reviews.
• Work with Case Manager, Care Navigator, and member concierge team.

Qualifications

• Education:
• Active and unencumbered Registered Nurse (RN) license required.
• Bachelor’s degree in nursing (BSN) preferred.
• Experience:
• Minimum of 3 years of clinical nursing experience, preferably in case management, utilization review, or managed care settings.
• Familiarity with self-funding, payer requirements, authorization process, clinical criteria, and healthcare delivery systems.
• Skills and Competencies:
• Advanced clinical knowledge to assess complex medical cases.
• Strong analytical, decision-making, and problem-solving abilities.
• Excellent verbal and written communication skills for interaction with diverse stakeholders.
• Proficiency in utilization review software.
• Knowledge of clinical guidelines (e.g., InterQual, Milliman) and regulatory requirements.

Work Environment

· Primarily office-based, with collaboration with clinical teams or external stakeholders.

· May involve high-volume workloads and deadlines requiring strong organizational skills and time management.

Performance Metrics

· Accuracy and timeliness of clinical reviews and authorizations.

· Success rate in overturning denials through appeals.

· Reduction in unnecessary hospital stays or procedures.

· Stakeholder satisfaction with communication and process efficiency.

Why Join Us?

As a Utilization Management RN, you will play a crucial role in driving healthcare excellence by balancing clinical expertise, patient advocacy, and cost-conscious decision-making. Your contributions will directly impact care outcomes, organizational success, and member satisfaction.

Job Type: Full-time

Pay: $66,560.00 - $72,880.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday
• No nights
• No weekends

Work Location: In person