Utilization Management - RN

Utilization Management - RN

This is a 6-month contract position with a possibility of an extension. Must have experience with Medicare Advantage. Must have experience with Concurrent Review, Inpatient, Utilization Management, Discharge Planning, and Transitions of Care.

Our client is seeking an experienced Concurrent Review Registered Nurse (RN) to join its Utilization Management team. In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care while collaborating with physicians, hospitals, and interdisciplinary teams to ensure members receive appropriate, cost-effective, and evidence-based care. This position is ideal for an RN with strong acute care experience and a background in managed care, utilization management, or case management.

What You Will Do:

• Perform concurrent, prior authorization, and retrospective utilization reviews.
• Evaluate medical necessity using InterQual, MCG, CMS, LCD/NCD, and health plan guidelines.
• Coordinate discharge planning and transitions of care with providers and healthcare facilities.
• Collaborate with physicians, hospital staff, specialists, and internal care management teams.
• Request and review additional clinical documentation when necessary.
• Escalate complex medical necessity cases to the Medical Director.
• Educate providers on utilization management policies and review criteria.
• Document all reviews and clinical decisions accurately within medical management systems.
• Identify care gaps and support quality improvement initiatives.
• Serve as a clinical resource for internal teams.

You Will Be Successful If:

• You have strong clinical judgment and are confident making medical necessity determinations.
• You can effectively communicate with physicians, hospitals, and multidisciplinary teams.
• You are highly organized and able to manage multiple cases simultaneously.
• You thrive in a fast-paced managed care environment.
• You are comfortable navigating challenging conversations regarding levels of care.
• You are detail-oriented and committed to delivering high-quality patient outcomes.

What You Will Bring:

• Active Registered Nurse (RN) license with the ability to obtain licensure in multiple states.
• Graduate of an accredited School of Nursing.
• Minimum 4 years of clinical nursing experience.
• Minimum 2 years of managed care or HMO experience.
• Experience performing medical necessity reviews using evidence-based clinical guidelines.
• Strong knowledge of: Concurrent Review, Utilization Management, Discharge Planning, Transitions of Care
• Experience applying: InterQual, MCG, CMS Guidelines
• Experience working with medical management software and Microsoft Office.
• Excellent communication, critical thinking, and organizational skills.

Preferred Experience:

• Bachelor of Science in Nursing (BSN).
• Emergency Department (ER) experience.
• Intensive Care Unit (ICU) experience.
• Case Management experience.
• Utilization Management experience within a health plan or managed care organization.
• Experience working directly with hospitals, physicians, and provider networks.