Licensed Utilization Management Nurse

Job Summary

A company is looking for a Utilization Management Nurse to review and monitor members' utilization of health care services.

Key Responsibilities

• Perform concurrent and retrospective reviews of facility and home health services while managing care for acutely and chronically ill patients
• Engage with providers for proactive discharge and transition planning, and determine observational vs acute inpatient status during prior authorization
• Maintain accurate records, monitor utilization reports for compliance, and coordinate interdisciplinary approaches to support continuity of care

Required Qualifications

• Minimum 2 years clinical experience as RN, LPN/LVN required
• Minimum 1-year managed care or equivalent health plan experience preferred
• Demonstrated experience in health plan utilization management and facility concurrent review discharge planning required
• Active unrestricted Nursing license required
• Experience with InterQual or MCG authorization criteria preferred