RN Utilization Management Specialist

Job Summary

A company is looking for a Clinical Guide Part A: Utilization Management (Inpatient, Behavioral Health & Post-Acute).

Key Responsibilities

• Conduct utilization reviews to evaluate medical necessity and appropriateness of inpatient and post-acute services
• Assess treatment plans for alignment with medical necessity criteria and recommend alternative care levels when needed
• Collaborate with the Medical Director for cases that do not meet criteria and maintain accurate documentation of determinations

Required Qualifications

• Unrestricted RN license with a minimum of 4 years of clinical experience
• Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting
• Strong knowledge of CMS regulations and Medicare Advantage requirements
• Experience preparing cases for Medical Director review
• Able to work in a fast-paced and evolving environment