Utilization Management Nurse, Senior

RemoteWorker US; Courtland; Remote; CAD 80,000 - 100,000; Full time

Job summary

A leading healthcare staffing firm is seeking a Utilization Management Nurse to review clinical information and ensure medical necessity for inpatient admissions. The role encompasses conducting utilization reviews, ensuring compliance with guidelines, and participating in discharge planning. Ideal candidates have a Bachelor's in Nursing, a California RN License, and at least 5 years of relevant experience. This full-time position offers the flexibility of remote work.

Qualifications

• 5+ years of relevant experience in utilization management.
• Current California RN License required.
• Experience in healthcare provider roles.

Responsibilities

• Perform utilization reviews and first-level determinations.
• Conduct clinical reviews of claims for medical necessity.
• Ensure appropriate discharge planning and post-acute needs.

Skills

Strong communication skills

Critical thinking

Teamwork

Independence

Computer skills

Education

Bachelor's of Science in Nursing

Job description

2 days ago Be among the first 25 applicants

Your Role

The Utilization Management team reviews inpatient stays for our members and applies guidelines for nationally recognized levels of care. The Utilization Management Nurse reports to the Nurse Manager. In this role, you will review clinical information from inpatient facilities to determine medical necessity for admissions. You will also participate in discharge planning and transfers for higher levels of care or out-of-network admissions.

Your Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews and first-level determinations using evidence-based guidelines, policies, and clinical criteria across lines of business, including Medicare and FEP.
• Conduct clinical reviews of claims for medical necessity, coding accuracy, and policy compliance.
• Ensure appropriate discharge planning, post-acute needs assessment, and levels of care, including durable medical equipment and post-service needs.
• Prepare and present cases to the Medical Director for oversight and necessity determinations, communicating decisions to providers and members in compliance with regulations.
• Develop and review documentation reflecting determinations, ensuring compliance with standards, and identify potential quality issues or delays.
• Refer cases to Case Management when inpatient needs impact discharge planning.
• Participate in staff meetings, clinical rounds, and weekly huddles.
• Maintain quality and productivity metrics.
• Support new employees and maintain HIPAA compliance in telework environments.

Your Qualifications and Experience

Bachelor's of Science in Nursing or higher degree preferred.

Current California RN License required.

At least 5 years of relevant experience preferred.

Strong communication and computer skills required.

Teamwork, collaboration, independence, critical thinking skills are essential.

Additional Information

Seniority level : Mid-Senior level

Employment type : Full-time

Job function : Healthcare Provider

Industries : Staffing and Recruiting

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