Remote Contract Utilization Management Nurse (RN)

Collab Capital; United States; On-site; USD 55,104 - 61,992; Full time

Benefits offered by this job

1 year contract with possibility of an

Collaborative work environment

Job summary

IntusCare is seeking a Contract Utilization Management Nurse to ensure high-quality, cost-effective, compliant care for PACE participants. This role partners with interdisciplinary teams and provider networks to review service utilization, guide care decisions, and support timely transitions across care settings.

Combines clinical expertise with analytics to ensure services are medically necessary and aligned with care plans and PACE regulations.

Qualifications

• 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.
• Excellent communication and leadership abilities, capable of motivating and guiding teams toward timely and efficient care management strategies.

Responsibilities

• Adhere to PACE program service authorization policies, ensuring that participant care and related claims are reasonable and necessary and aligned with PCP coordination decisions.
• Active involvement in utilization management process: concurrent review of hospital admissions with IDT, retrospective review of inpatient admissions under 48 hours, and ensuring service authorization consistency.
• Concurrent review of subacute and SNF admissions with IDT to drive efficient discharge plans and transitions of care.
• Coordinate and review other contracted services to assure consistency with care plans and PCP decisions.
• Advocate for quality care, improved outcomes, and reduced hospital stays; maintain accurate patient records.
• Lead provider appeals process for claim rejections in collaboration with Medical Director.

Skills

Utilization management experience

RN license

Risk-based care models

Data-driven decisions

Strategic thinking

Communication & leadership

Education

RN license

Job description

IntusCare is seeking a Contract Utilization Management Nurse to ensure high-quality, cost-effective, compliant care for PACE participants. This role partners with interdisciplinary teams and provider networks to review service utilization, guide care decisions, and support timely transitions across care settings.

Combines clinical expertise with analytics to ensure services are medically necessary and aligned with care plans and PACE regulations.