RN Utilization & Care Optimization Specialist

ArchWell Health; Nashville (TN); On-site; USD 85,000 - 110,000; Full time

Job summary

ArchWell Health is seeking an experienced Utilization Management Nurse to ensure patients receive appropriate, cost-effective care by reviewing medical services and treatment plans. You will identify opportunities to educate providers and collaborate to optimize resource utilization and improve outcomes.

The role requires an active RN license and 3+ years in utilization management, with travel up to 20% and strong knowledge of value-based care and CMS guidelines.

Qualifications

• Must hold an active RN license in state(s) of employment.
• AA/AS nursing degree required; BSN preferred.
• Minimum 3 years of direct utilization management experience.
• Experience in acute care or senior health settings preferred.

Responsibilities

• Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity to ensure treatment and services are appropriate and necessary by reviewing medical records and treatment plans.
• Works collaboratively with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determination reviews as applicable utilizing CMS clinical guidelines and insurance policies.
• Maintains accurate and detailed records of reviews, interventions, and communications to ensure adherence to health plan requirements and organizational policies.
• Analyze utilization trends to ensure progress towards organizational goals
• Educates healthcare providers and patients regarding appropriate levels of care and service criteria and guidelines.
• Collaborates with Network and specialists to identify opportunities to educate on value-based care, resolve specialty gaps by markets, improve cost-effectiveness and coordination of care to meet patient needs.

Skills

Utilization management

Data analysis

Healthcare regulations

Emotional intelligence

Creativity and initiative

Cross-functional collaboration

Spanish language (helpful)

Education

AA/AS Nursing

RN license

BSN preferred

Healthcare Administration degree desirable

Job description

ArchWell Health is seeking an experienced Utilization Management Nurse to ensure patients receive appropriate, cost-effective care by reviewing medical services and treatment plans. You will identify opportunities to educate providers and collaborate to optimize resource utilization and improve outcomes.

The role requires an active RN license and 3+ years in utilization management, with travel up to 20% and strong knowledge of value-based care and CMS guidelines.