Remote UM Lead & CDI Mentor (RN)

Omega Healthcare Management Services Pvt. Ltd.; Boca Raton (FL); Remote; USD 90,000 - 120,000; Full time

Job summary

Omega Healthcare Management Services Pvt. Ltd. is seeking a Clinical Utilization Management RN to lead review programs and collaborate with care teams in a remote home-office setting.

The role requires strong knowledge of InterQual criteria, Medicare guidelines, and payer policies, with UR/UM experience and staff mentoring. Responsibilities include medical necessity reviews, coordinating authorizations, developing standardized workflows, and KPI monitoring to drive regulatory compliance and

Qualifications

• Bachelor’s degree in nursing and active RN license.
• 3–5 years hospital-based Utilization Review/Utilization Management experience.
• Working knowledge of InterQual criteria, Medicare regulations, and DRG assignment.

Responsibilities

• Conduct medical necessity, admission, continued-stay, and status reviews using InterQual criteria, Medicare guidelines, and payer policies.
• Evaluate clinical documentation, identify gaps, and coordinate timely payer authorizations and physician escalations.
• Develop, implement, and standardize UM/UR workflows and escalation processes to improve efficiency and compliance.
• Provide leadership and mentorship to hospital Care Coordination/UR staff.
• Collaborate with physicians and hospital leadership to optimize utilization management and patient status accuracy.
• Monitor program performance, establish KPIs, and develop utilization and LOS reports.

Skills

CDI

Microsoft Excel

Microsoft Outlook

Microsoft Teams

Education

BSN

RN license

Tools

Epic

Access database

Utilization review queues

Job description

Omega Healthcare Management Services Pvt. Ltd. is seeking a Clinical Utilization Management RN to lead review programs and collaborate with care teams in a remote home-office setting.

The role requires strong knowledge of InterQual criteria, Medicare guidelines, and payer policies, with UR/UM experience and staff mentoring. Responsibilities include medical necessity reviews, coordinating authorizations, developing standardized workflows, and KPI monitoring to drive regulatory compliance and