Licensed Utilization Management Nurse

Job Summary

To enhance the quality and cost-effectiveness of healthcare services, the full-time Licensed Utilization Management Nurse will review and monitor members' utilization of services, provide prior authorizations, and engage in proactive discharge planning, all while working remotely with occasional weekend coverage.

Key responsibilities

• Perform concurrent and retrospective reviews of facility and home health services, managing care for acutely and chronically ill patients
• Engage with providers for proactive discharge and transition planning, ensuring compliance with notification processes
• Coordinate interdisciplinary approaches to support continuity of care and identify opportunities for cost savings and quality improvements

Required qualifications

• Minimum 2 years of clinical experience as an RN, LPN, or LVN
• At least 1 year of managed care or equivalent health plan experience preferred
• Experience in health plan utilization management and facility concurrent review required
• Active unrestricted Nursing license required
• Familiarity with InterQual or MCG authorization criteria preferred