Registered Nurse Utilization Review

APN Consulting Inc.; California (MO); Remote; USD 70,000 - 85,000; Full time

Job summary

A leading healthcare provider is seeking a Registered Nurse for Utilization Management. This remote position involves promoting quality care by reviewing medical necessity, collaborating with medical teams, and ensuring effective discharge planning. Ideal candidates will have a nursing degree and experience in medical management. Join us to make a difference in patient care while enjoying the flexibility of remote work.

Qualifications

• Minimum 2 years of experience in medical management clinical functions.

Responsibilities

• Perform medical necessity reviews for assigned members.
• Collaborate with Medical Director on adverse determination notices.
• Ensure timely discharge planning and communication.

Skills

Collaboration

Patient-Centered Care

Education

Associate's degree in nursing

Tools

MCG

InterQual

NCQA standards

Job description

1 month ago Be among the first 25 applicants

Position Title: Registered Nurse Utilization Management

Location: Remote

Shift Type: 8am - 5pm PDT; Workdays/Hours may include 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 members to receive necessary services and resources. The role involves providing patient-centered care across the continuum.

Role and Responsibilities:

1. Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members.
2. Review cases for medical necessity using clinical criteria such as Medicare, Medicaid, InterQual, Milliman, or health plan-specific guidelines.
3. Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on quality standards.
4. Ensure timely and appropriate 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 Requirements:

• Associate's degree in nursing preferred.
• Minimum 2 years of 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