Medicare Utilization Review RN — Care Optimization

American Health Plans; Franklin (TN); Remote; USD 65,000 - 95,000; Full time

Benefits offered by this job

Health insurance

Paid time off & holidays

TeleDoc access

Disability plans (short/long-term)

Employee Assistance Plan (EAP)

401K with company match

Employee Referral Bonus

Job summary

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., is seeking an Utilization Review Nurse to assess medical necessity across pre-service, concurrent, and retrospective reviews. You will support the Clinical Services Department and Medical Director to ensure compliant, high-quality care for members.

The role requires an RN license, 1+ year UM experience, and knowledge of InterQual/MCG clinical criteria, with opportunities in a multi-state Medicare

Qualifications

• Minimum 1 year of utilization management experience in a health plan or hospital-based UM department.
• CCM credential is a plus to consider; RN licensure required.
• Knowledge of Medicare regulations and URAC/NCQA principles.

Responsibilities

• Assess medical necessity, quality of care, and level of care for plan members.
• Identify best placement settings based on medical necessity.
• Coordinate with providers to gather data and apply review criteria.
• Certify cases meeting criteria and consult when needed.
• Maintain regulatory timeframes in utilization management reviews.

Skills

UR/utilization management

clinical assessment

communication skills

independent work

Education

Associates or better in Nursing

Registered Nurse license

Tools

InterQual

MCG

Job description

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., is seeking an Utilization Review Nurse to assess medical necessity across pre-service, concurrent, and retrospective reviews. You will support the Clinical Services Department and Medical Director to ensure compliant, high-quality care for members.

The role requires an RN license, 1+ year UM experience, and knowledge of InterQual/MCG clinical criteria, with opportunities in a multi-state Medicare