Utilization Management Registered Nurse

Utilization Management Registered Nurse (UM RN)

We're seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to join our growing healthcare team. In this role, you'll perform both inpatient and outpatient utilization reviews while supporting transitions of care and ensuring patients receive appropriate, timely, and high-quality services.

The ideal candidate will bring strong clinical judgment, inpatient/SNF experience, and familiarity with MCG guidelines and Medicare Advantage regulations (LCD/NCD policies). This is a fully remote opportunity requiring discipline, accuracy, and effective collaboration across virtual teams.

Key Responsibilities:

• Conduct clinical reviews of inpatient, outpatient, and SNF services to assess medical necessity, appropriateness, and efficiency using evidence-based criteria (e.g., MCG).
• Evaluate and process prior authorization (PA) requests in a timely, compliant manner.
• Collaborate with inpatient providers and case managers to support Transitions of Care (TOC) and discharge planning.
• Communicate clearly with interdisciplinary teams to ensure coordinated and effective care delivery.
• Maintain accurate, comprehensive documentation in systems such as AcuityNxt and other electronic platforms.
• Ensure compliance with Medicare Advantage, state, and federal healthcare regulations.
• Contribute to process improvement initiatives to enhance overall UM effectiveness and efficiency.

What You'll Bring:

• Active, unrestricted RN license (state-specific or compact).

• 3+ years of Utilization Management or related clinical review experience.

• Proven experience with Skilled Nursing Facility (SNF) utilization reviews.

• Strong familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage rules.

• Prior experience in prior authorization (PA) and Transitions of Care (TOC) workflows.

• Excellent clinical communication skills and confidence in engaging with inpatient providers.

• Strong attention to detail, documentation accuracy, and compliance focus.

• Tech-savvy with the ability to quickly adapt to healthcare systems and remote work tools.

Why Join Us:

• 100% Remote role – enjoy work-life balance while supporting patients across the continuum of care.

• Collaborative, mission-driven healthcare environment.

• Opportunity to expand into Transitions of Care (TOC) initiatives and process optimization.

• Competitive compensation and benefits package.