Registered Nurse Utilization Manager

Job Summary

To ensure high-quality, cost-effective care for PACE participants, the full-time Contract Utilization Management Nurse will manage service utilization reviews, guide care decisions, and support transitions across care settings in a remote environment.

Key responsibilities

• Ensure adherence to PACE program service authorization policies and medical necessity of services
• Conduct concurrent and retrospective reviews of hospital and subacute admissions, collaborating with the Interdisciplinary Team for efficient care transitions
• Lead the provider appeals process for claim rejections, working with the Medical Director to ensure compliance with PACE program policies

Required qualifications

• 3 to 5 years of utilization management experience
• Current RN license
• Experience in risk-based integrated models of care
• Ability to utilize data for decision-making and collaboration
• Strong strategic thinking and leadership skills