Registered Nurse Utilization Review

APN Consulting Inc.; California (MO); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Registered Nurse for Utilization Management. This role focuses on promoting quality and cost-effective outcomes through collaboration and patient-centered care. The ideal candidate will perform medical necessity reviews, apply clinical criteria, and ensure effective discharge planning. This position offers the opportunity to work remotely while contributing to essential healthcare services. If you are passionate about improving patient outcomes and have the necessary experience, this is a fantastic opportunity to join a dynamic team.

Qualifications

• Experience in conducting medical necessity reviews for various cases.
• Knowledge of clinical criteria and standards in healthcare.

Responsibilities

• Perform medical necessity reviews for assigned members.
• Collaborate with the Medical Director on adverse determinations.

Skills

Medical Necessity Reviews

Clinical Criteria Application

Patient-Centered Care

Collaboration with Medical Director

Education

Associate's Degree in Nursing

2+ Years Experience in Medical Management

Tools

MCG

InterQual

NCQA Standards

Job description

Position Title: Registered Nurse Utilization Management

Location: Remote

Shift Type: 8am - 5pm PDT. Workdays/Hours: Including evenings, weekends, and holidays.

Contract Duration: 3 Months (Temp to Perm Possibility)

Overview:

The UM Nurse promotes quality, cost-effective outcomes by facilitating collaboration across settings, identifying member needs, planning care, monitoring interventions, and advocating for necessary services to meet health and social outcomes. The role involves providing patient-centered care across the continuum.

Role and Responsibilities:

1. Perform prospective, retrospective, or concurrent medical necessity reviews for assigned members.
2. Review cases for medical necessity, applying clinical criteria such as Medicare, Medicaid, InterQual, Milliman, or specific health plan guidelines.
3. Collaborate with the Medical Director to ensure the integrity of adverse determination notices.
4. Ensure timely discharge planning and communication with transition of care teams.
5. Meet or exceed productivity targets.
6. Serve as a resource to non-clinical team members when applicable.

Qualifications and Education:

• Associate's degree in nursing preferred.
• Minimum of 2 years experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards.

Additional Details:

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Other
• Industries: IT Services and IT Consulting