Utilization Management Nurse- Full Time- HYBRID

About the position

The Utilization Management (UM) Nurse is responsible for overseeing and ensuring the quality and cost efficiency of healthcare services through various UM-related activities. This role involves conducting medical necessity reviews, coordinating care, and ensuring compliance with regulatory standards. The UM Nurse will work collaboratively with healthcare teams to facilitate effective patient care and discharge planning.

Responsibilities
• Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines.
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• Performs level of care (LOC) determinations and monitors length of stay based on severity of illness and intensity of service using the appropriate clinical criteria.
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• Conducts initial clinical review (in accordance with accreditation, laws, and regulations).
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• Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews.
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• Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
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• Coordinates discharge planning needs and transition of care with the registered nurse case managers and other healthcare team members, as deemed appropriate.
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• Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated.
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• Collaborates with a multi-disciplinary staff and interdepartmentally.
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• Establishes and maintains professional relationships with providers and facilities to establish a smooth operational flow of authorizations and referrals.
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• Evaluates, coordinates, manages, and documents all UM-related activities.
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• Maintains a current knowledge of medical necessity criteria and UM-related policies and procedures.
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• Assists in the development and maintenance of medical necessity criteria and clinical pathways.
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• Participates in the monitoring of the effectiveness and outcomes of the UM program.
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• Participates in UM program process improvement initiatives.
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• Complies with all regulatory and accreditation standards related to utilization management and/or case management.
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• Complies with Utilization Management and Case Management standards of practice.
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• Performs other duties as assigned.

Requirements
• Associate's degree in nursing required.
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• Current active, unrestricted state licensure as a Registered Nurse is required.
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• 0 - 2 years of experience in utilization management or case management is preferred.
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• Knowledge of Medicare is preferred.
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• Knowledge of Medicaid, HMO, and private insurance is preferred.

Nice-to-haves
• Bachelor's degree in nursing preferred.
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• Utilization Management or Case Management certification is preferred.
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• Professional license must be with a scope of practice that will be relevant to initial clinical review.
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• Clinical background and judgement to conduct initial clinical review is required.

Benefits
• Hybrid work environment
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• Flexible scheduling options
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• Professional development opportunities

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