Remote Part-Time Utilization Management Nurse

nirvanaHealth, LLC; Southborough (MA); Remote; USD 52,000 - 55,000; Part time

Job summary

nirvanaHealth, LLC in Southborough, MA is seeking a Utilization Management (UM) Nurse for a part-time remote role. The position totals 12 hours per week across Friday evening and Saturday/Sunday shifts.

The UM Nurse performs prospective, concurrent, and retrospective medical necessity reviews, makes level of care determinations, and ensures regulatory compliance. An RN license is required; Medicare/Medicaid knowledge is preferred.

Qualifications

• Associate's degree in nursing required.
• Bachelor's degree in nursing preferred.
• 0-2 years in UM or case management preferred.
• Medicare knowledge preferred.
• Medicaid/HMO/private insurance knowledge preferred.
• NCQA/URAC accreditation knowledge preferred.

Responsibilities

• Performs prospective, concurrent, and retrospective medical necessity reviews.
• Performs level of care determinations and monitors length of stay.
• Conducts initial clinical review in accordance with laws and regulations.
• Ensures timeliness of medical necessity reviews per guidelines.
• Verifies accuracy of codes and services with documentation.
• Coordinates discharge planning with registered nurse case managers and team.
• Communicates criteria and rationale to members, providers, and facilities.
• Collaborates with multidisciplinary staff to ensure smooth authorizations and referrals.
• Maintains knowledge of medical necessity criteria and UM policies.

Skills

Clinical judgement

Regulatory compliance

Education

Associate's degree in nursing

Bachelor's degree in nursing

Tools

MS Word

Excel

Access

PowerPoint

Job description

nirvanaHealth, LLC in Southborough, MA is seeking a Utilization Management (UM) Nurse for a part-time remote role. The position totals 12 hours per week across Friday evening and Saturday/Sunday shifts.

The UM Nurse performs prospective, concurrent, and retrospective medical necessity reviews, makes level of care determinations, and ensures regulatory compliance. An RN license is required; Medicare/Medicaid knowledge is preferred.