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 remotely, ensuring compliance with CMS and Medicare Advantage regulations.

Key responsibilities:

• Review medical records to evaluate medical necessity and appropriateness of inpatient and post-acute services
• Assess treatment plans for alignment with medical necessity criteria and recommend alternative levels of care when appropriate
• Perform concurrent and discharge reviews for inpatient and behavioral health admissions, ensuring regulatory compliance

Required qualifications:

• Unrestricted RN license with a minimum of 4 years of clinical experience
• 3+ years in utilization review, case management, or clinical appeals in a health plan or hospital setting
• Familiarity with CMS regulations and Medicare Advantage requirements
• Experience escalating cases that do not meet criteria, including preparing clinical summaries
• Ability to work one of the posted schedules, including a weekend day for most schedules