Utilization Management Nurse

Utilization Management Nurse

IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. IntusCare empowers teams to take control of their operations and improve outcomes for dual-eligible seniors – some of the most socially vulnerable and clinically complex individuals in the US healthcare system.

The Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This individual partners closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks to review service utilization, guide care decisions and support timely, appropriate transitions across care settings. Blending clinical expertise with analytical thinking, the Utilization Management Nurse ensures services are medically necessary, aligned with care plans and consistent with PACE regulations and best practices. This role is essential to maintaining program integrity, improving participant outcomes and supporting the delivery of coordinated, value-based care.

Responsibilities include rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions. Active involvement in various aspects of the utilization management process, including concurrent review of all hospital admissions, retrospective review of inpatient admissions under 48 hours, and coordination and review of all other services delivered by contracted providers. Employ effective use of knowledge, critical thinking, and skills to advocate quality care and enhanced quality of life, maintain accurate records of all patient related interactions, and appeal management in cases of claim rejection.

Qualifications include 3 to 5 years of utilization management experience, current RN license, proven experience working in risk based integrated models of care, ability to use data to drive decisions and collaboration with internal and external stakeholders, strong strategic thinking, problem solving, and decision making skills, and excellent communication and leadership abilities.

What We Offer includes a chance to be a part of a trailblazing team in healthcare technology, competitive salary and equity package, comprehensive benefits including health, dental, and vision insurance, a collaborative, inclusive, and dynamic work environment, and opportunities for professional growth and development.

Compensation: The salary range for this role is $80K-$95K. Work location: This is a fully remote role based in the United States. Sponsorship: This position is not eligible for sponsorship.