RN - Utilization Management

Utilization Management Registered Nurse (UM RN)

We are seeking an experienced and detail-oriented Utilization Management Registered Nurse (UM RN) to join our hospital team. The UM RN is responsible for reviewing patient cases to ensure appropriate utilization of healthcare services, medical necessity, compliance with payer requirements, and optimal patient outcomes. This role collaborates closely with physicians, case managers, and interdisciplinary teams to support quality patient care while managing healthcare resources efficiently.

Key Responsibilities

• Perform utilization review activities for inpatient and outpatient services.
• Assess medical necessity, level of care, and appropriateness of admissions using established criteria such as InterQual or MCG guidelines.
• Collaborate with physicians, case management, and healthcare teams regarding patient care plans and discharge planning.
• Communicate with insurance providers and third-party payers to obtain authorizations and resolve coverage issues.
• Monitor patient length of stay and identify opportunities to improve care efficiency.
• Ensure compliance with hospital policies, federal regulations, and payer requirements.
• Document utilization review findings accurately and maintain confidentiality of patient information.
• Participate in denial prevention and appeals processes when necessary.
• Support quality improvement initiatives and patient care coordination activities.

Qualifications

• Active Registered Nurse (RN) license in the applicable state.
• Bachelor of Science in Nursing (BSN) preferred.
• Minimum 23 years of acute care hospital nursing experience required.
• Prior experience in Utilization Management, Case Management, or Care Coordination preferred.
• Strong knowledge of InterQual and/or MCG criteria.
• Experience working with electronic medical records (EMR) systems.
• Excellent communication, critical thinking, and organizational skills.