Utilization Management Nurse

Our client, a leading California healthcare organization providing medical, dental, vision, Medicare, and Medicaid health plans, seeks an experienced Utilization Management Nurse (RN) for a remote opportunity supporting inpatient utilization review, medical necessity determinations, and facility claims compliance. Duration: 6 Months Contract with Possible Extension Pay Rate: $55/hour on W2 Work Arrangement: Remote Position Overview The Utilization Management Nurse will support the Facility Compliance Review team by conducting retrospective utilization reviews, evaluating inpatient hospital claims, and ensuring compliance with medical necessity criteria, industry billing standards, and facility contracts. This position involves reviewing clinical documentation, performing detailed hospital bill audits, validating DRG classifications, and collaborating with Medical Directors to support accurate claims determinations. Key Responsibilities Perform retrospective utilization reviews and first-level determination approvals using evidence-based clinical guidelines and nationally recognized criteria. Review inpatient facility claims for medical necessity, coding accuracy, medical policy compliance, and contractual requirements. Conduct comprehensive line-by-line audits of hospital itemized bills to identify billing discrepancies and ensure contract compliance. Review complex claims involving DRG validation, stop-loss, trauma, emergency services, burns, implants, NICU, transplants, and hospital-acquired conditions. Evaluate clinical documentation to determine appropriate levels of care. Prepare and present cases to Medical Directors for medical necessity determinations and oversight. Communicate utilization review determinations to providers and members in accordance with state, federal, and accreditation requirements. Develop accurate clinical documentation and determination correspondence. Review coding logic using industry billing standards and CMS guidelines. Identify potential quality-of-care concerns, treatment delays, and service issues. Prioritize assigned cases to meet required turnaround times. Apply clinical judgment and knowledge of health plan benefits when making review decisions. Required Qualifications Active California Registered Nurse (RN) license. Minimum 5 years of relevant professional experience. Experience with concurrent or post-service inpatient reviews. Bachelor's degree or equivalent experience. Strong clinical judgment, analytical skills, and ability to interpret medical documentation. Excellent computer navigation, communication, and documentation skills. Ability to work independently, manage priorities, and meet deadlines. Preferred Qualifications Experience reviewing inpatient claims within a managed care or health insurance environment. Experience with retrospective utilization review, medical necessity determinations, or facility claims audits. Previous Electronic Medical Records (EMR) experience. Familiarity with Microsoft Office, Outlook, and Microsoft Teams. Key Areas of Expertise Utilization Management (UM) | Utilization Review (UR) | Retrospective Review | Inpatient Claims Review | Managed Care | Medical Necessity Review | Facility Claims Audit | DRG Validation | Clinical Documentation Review | CMS Guidelines | Hospital Billing Compliance | Registered Nurse (RN) Company Overview Amerit Consulting is a nationwide staffing and consulting firm supporting Fortune 500 clients across healthcare, technology, engineering, and professional services. With over 2,000 employees across 47 states, Amerit specializes in contract, temporary, and direct hire staffing solutions. Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws. #J-18808-Ljbffr Amerit Consulting