Utilization Management Nurse (RN)

Job Summary

To support the Utilization Management team, the full-time Utilization Management Nurse (RN) will conduct inpatient, behavioral health, and post-acute authorization reviews, ensuring compliance with CMS and Medicare Advantage regulations while working remotely.

Key responsibilities

• Review medical records to evaluate medical necessity and appropriateness of requested services through prospective, concurrent, and retrospective utilization reviews
• Assess treatment plans for alignment with medical necessity criteria and recommend alternative levels of care when appropriate
• Collaborate with the Medical Director on cases that do not meet criteria and maintain accurate documentation of all determinations

Required qualifications

• Unrestricted RN license with a minimum of 4 years of clinical experience
• At least 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, evolving environment