Utilization Management Nurse RN
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Job Summary
To support timely and compliant care decisions, the full-time Utilization Management Nurse RN will review medical necessity requests, apply evidence-based criteria, and document determinations while working Monday to Friday, 8:00 AM-5:00 PM Pacific Time, with occasional Saturday coverage.
Key responsibilities
- Perform medical-necessity reviews and level-of-care determinations using plan documents and evidence-based criteria
- Analyze clinical records for completeness and escalate cases to the Medical Director when necessary
- Document reviews and outcomes accurately in designated UM systems to ensure audit readiness
Required qualifications
- Current, unrestricted RN license in the United States or a U.S. territory
- Graduate of an accredited nursing program (ADN or diploma required; BSN preferred)
- Minimum 1-2 years of recent clinical experience in acute care or relevant settings
- Prior utilization review or utilization management experience preferred
- Working knowledge of MCG, NCCN standards, and HIPAA requirements
Complete Job Description
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