Remote RN Utilization Management Specialist

McLaren Health Care; Mount Clemens (MI); Hybrid; USD 85,000 - 105,000; Full time

Job summary

McLaren Health Care is seeking a Registered Nurse to join the Utilization Management team. The role focuses on determining appropriate patient status, ensuring medical necessity, and documenting care for insurance and government payers within an acute care hospital context.

You will collaborate with admitting physicians and care teams, conduct concurrent reviews, and support discharge planning while maintaining compliance with payer requirements and clinical guidelines.

Qualifications

• RN license is required.
• Bachelor's degree in nursing or actively pursuing with plan to obtain 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 teams to determine appropriate inpatient vs. outpatient settings based on medical necessity.
• Expedite patient discharge with ICM services; verify documentation supports level of care and payer requirements.
• Screen documentation for timeliness, completeness, and appropriateness related to medical necessity and payer rules.
• Document clinical reviews, payer authorizations, and discharge planning in the EMR and related tools.
• Facilitate peer-to-peer reviews with payers and providers as needed.
• Participate in interdisciplinary rounds to review continued stays and LOS outliers.
• Collaborate with providers to address medical necessity questions per SOPs.

Skills

Utilization management

Nursing

Clinical documentation

Education

RN licensure

Bachelor's in Nursing

Tools

EMR (Electronic Medical Record)

Veracity

Optum

InterQual

Milliman

Job description

McLaren Health Care is seeking a Registered Nurse to join the Utilization Management team. The role focuses on determining appropriate patient status, ensuring medical necessity, and documenting care for insurance and government payers within an acute care hospital context.

You will collaborate with admitting physicians and care teams, conduct concurrent reviews, and support discharge planning while maintaining compliance with payer requirements and clinical guidelines.