Remote RN Utilization Management Specialist

McLaren Health Care; Mount Clemens (MI); Hybrid; USD 75,000 - 110,000; Full time

Job summary

McLaren Health Care is seeking a registered nurse to lead utilization management activities, determining appropriate patient status and medical necessity in collaboration with the care team. The role focuses on concurrent reviews, documentation, and ensuring compliant hospital admissions and discharge planning, with a remote-first setup and occasional in-person requirements.

You will document in the EMR, coordinate with payers, and participate in peer reviews.

Qualifications

• RN state licensure is required.
• Bachelor’s degree in nursing or actively pursuing degree to be completed within five years.
• Three years of recent nursing or utilization management experience in an acute care hospital.

Responsibilities

• Perform concurrent and retrospective utilization management reviews to track, evaluate, and report data.
• Collaborate with care team to determine appropriate hospital setting based on medical necessity.
• Work with ICM service lines to expedite patient discharge and optimize reimbursements.
• Screen documentation for timeliness, appropriateness, and completeness related to utilization management.
• Document in EMR including medical necessity, payer authorizations, avoidable days, and discharge planning.

Skills

RN licensure

Utilization management experience

Acute care nursing experience

Clinical documentation

Education

Bachelor's degree in Nursing

Tools

EMR (Electronic Medical Records)

Veracity

Optum

InterQual

Milliman

Job description

McLaren Health Care is seeking a registered nurse to lead utilization management activities, determining appropriate patient status and medical necessity in collaboration with the care team. The role focuses on concurrent reviews, documentation, and ensuring compliant hospital admissions and discharge planning, with a remote-first setup and occasional in-person requirements.

You will document in the EMR, coordinate with payers, and participate in peer reviews.