Utilization Management Nurse

At Duly Health and Care, you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do. With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve. Benefits Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance. Access to a mental health benefit at no cost. Employer provided life and disability insurance. $5,250 Tuition Reimbursement per year. Immediate 401(k) match. 40 hours paid volunteer time off. A culture committed to community engagement and social impact. Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met. The Utilization Management Registered Nurse is responsible for conducting utilization management reviews to ensure members receive medically necessary, appropriate, and cost-effective care. The UM RN performs initial and concurrent reviews across inpatient, observation, skilled nursing, acute rehabilitation, LTACH, home health, and other applicable services. The UM RN applies MCG/InterQual criteria, health plan guidelines, CMS regulations, and organizational policies to evaluate medical necessity, level of care, length of stay, and discharge needs. The UM RN collaborates with Medical Directors, providers, facilities, members, families, and interdisciplinary teams to promote quality outcomes and timely transitions of care. The UM RN also supports quality gap closure, care coordination, quality improvement initiatives, NCQA accreditation requirements, and departmental performance goals, while maintaining established productivity, quality, documentation, compliance, and turnaround-time KPIs. ESSENTIAL DUTIES AND RESPONSIBILITIES Performs initial and concurrent utilization reviews for inpatient, observation, SNF, acute rehabilitation, LTACH, home health, and other services as assigned. Determines medical necessity and appropriateness of care using MCG/InterQual, health plan guidelines, CMS regulations, NCQA standards, and departmental policies. Evaluates level of care, length of stay, treatment plans, and discharge needs and identifies opportunities for appropriate transitions to lower levels of care. Refers cases not meeting established criteria to the Medical Director and communicates determinations to appropriate parties. Collaborates with providers, facilities, Medical Directors, case managers, social workers, and other interdisciplinary team members to facilitate timely and appropriate discharge planning. Identifies barriers to discharge and coordinates medically necessary services, authorizations, referrals, and transitions of care. Identifies members requiring ongoing case management or additional clinical support and makes appropriate referrals. Supports quality initiatives and quality gap closure by identifying opportunities related to preventive care, chronic disease management, screenings, follow-up care, medication adherence, and other applicable quality measures. Communicates identified quality gaps to appropriate clinical teams and assists with interventions and closure when applicable. Maintains established UM KPIs, including productivity, turnaround time, documentation accuracy, quality, compliance, and service-level expectations. Supports the organization's efforts to achieve and maintain NCQA accreditation standards by adhering to applicable policies, workflows, documentation requirements, utilization management standards, and audit requirements. Participates in NCQA, health plan, regulatory, and internal audits and ensures assigned UM activities and documentation meet applicable accreditation and regulatory standards. Identifies and escalates potential quality-of-care or quality-of-service concerns and participates in quality assurance and improvement activities. Reviews utilization data and reports, including admissions, length of stay, avoidable days, readmissions, and other assigned metrics, and identifies opportunities for improvement. Participates in UM committees, staff meetings, education, special projects, and process improvement initiatives. Maintains accurate, timely, and compliant documentation and protects member confidentiality in accordance with HIPAA and organizational policies. Maintains current knowledge of utilization management, Medicare Advantage, managed care, NCQA standards, regulatory requirements, quality initiatives, and clinical guidelines. Performs other duties as assigned. KNOWLEDGE, SKILLS AND ABILITIES Knowledge of utilization management and medical necessity criteria, including MCG/InterQual. Knowledge of Medicare Advantage, HMO, managed care, and post-acute care. Knowledge of NCQA accreditation standards and regulatory requirements preferred. Knowledge of quality measures and quality gap closure. Strong clinical assessment, critical thinking, communication, and documentation skills. Ability to manage multiple priorities and meet productivity, quality, compliance, and turnaround-time expectations. Proficiency with electronic medical records; Epic/Tapestry experience preferred. Ability to work effectively in a multidisciplinary and metrics-driven environment. EDUCATION AND/OR CERTIFICATION/LICENSURE Associate/Diploma or Bachelor\'s Degree in Nursing from an accredited nursing program. Current, unrestricted Registered Nurse (RN) license. CCM or ACM certification preferred. EXPERIENCE Minimum of two (2) years of clinical nursing experience, preferably in an acute care setting. Two (2) years of experience in Utilization Management, concurrent review, or Case Management in a health plan or hospital setting preferred. Experience with Medicare Advantage and HMO populations preferred. Experience with NCQA accreditation, quality improvement, HEDIS/Stars, or quality gap closure preferred. The compensation for this role includes a base pay range of $67,953.60- $101K with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Lets start with what matters. People. Purpose. Care. At Duly Health and Care, we believe healthcare works best when it’s personal, connected, and led by people who truly care. We are a physician-led medical group built on trusted relationships, teamwork, and a shared commitment to putting patients first in every decision we make. Our team members are caregivers, collaborators, problem-solvers, and leaders. Together, we show up with compassion, act with purpose, and take ownership of the care we deliver and the experience we create. Whether you’re caring directly for patients or supporting the teams who do, your role matters here, and your voice is valued. We listen with intention, work as one, and challenge ourselves to keep improving, not for recognition, but because our patients, families, and communities count on us. Innovation at Duly isn\'t about chasing what\'s next for its own sake. It\'s about finding better ways to deliver high-quality, affordable, and accessible care, today and into the future. If you\'re looking for meaningful work, supportive teammates, and the opportunity to help shape the future of care while staying grounded in compassion and community, you\'ll find your place at Duly. If you are committed to putting our patients first and helping shape the future of care, you belong at Duly. Current Duly Health and Care team members: #J-18808-Ljbffr