Utilization Management Nurse - RN

Job Summary

Working remotely on a full-time basis, the Utilization Management Nurse - RN will review and monitor members' healthcare service utilization, focusing on prior authorizations, concurrent reviews, and proactive discharge planning, with a shift schedule of either Sun-Thurs or Tues-Sat.

Key responsibilities

• Performs concurrent and retrospective reviews on facility and home health services, managing care for acutely and chronically ill patients
• Determines observational vs acute inpatient status as part of the hospital prior authorization process
• Engages with providers for proactive discharge and transition planning while preparing necessary CMS-compliant notification letters

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 required
• Active unrestricted Nursing license required
• Experience with InterQual or MCG authorization criteria preferred