Utilization Management Nurse

Job Summary

A company is looking for a Utilization Management Nurse to review and monitor members' utilization of health care services to maintain high quality cost-effective care.

Key Responsibilities

• Perform concurrent and retrospective reviews of health services and manage 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
• Coordinate interdisciplinary approaches to support continuity of care and identify opportunities for cost savings and quality improvement

Required Qualifications

• Minimum 2 years of clinical experience as an RN, LPN/LVN required
• Minimum 1 year of managed care or equivalent health plan experience preferred
• 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