RN - Utilization Management

Central Business Solutions, Inc; Franklin (NH); On-site; USD 80,000 - 105,000; Full time

Job summary

Central Business Solutions, Inc. in Franklin, NH seeks an experienced Utilization Management Registered Nurse (UM RN) to review patient cases for appropriate utilization of services, medical necessity, and payer requirements.

The role collaborates with physicians, case managers, and care teams to support quality patient care and efficient resource use. Responsibilities include performing utilization reviews for inpatient/outpatient services, assessing level of care, coordinating with payers for

Qualifications

• Active RN license in the applicable state.
• BSN preferred.
• Minimum 2–3 years of acute care hospital nursing experience.
• Prior experience in Utilization Management, Case Management, or Care Coordination preferred.
• Strong knowledge of InterQual and/or MCG criteria.
• Experience working with electronic medical records (EMR) systems.
• Excellent communication, critical thinking, and organizational skills.

Responsibilities

• Perform utilization review activities for inpatient and outpatient services.
• Assess medical necessity, level of care, and appropriateness of admissions using InterQual or MCG criteria.
• Collaborate with physicians, case management, and healthcare teams regarding patient care plans and discharge planning.
• Communicate with insurance providers and third-party payers to obtain authorizations and resolve coverage issues.
• Monitor patient length of stay and identify opportunities to improve care efficiency.
• Ensure compliance with hospital policies, federal regulations, and payer requirements.
• Document utilization review findings accurately and maintain confidentiality of patient information.
• Participate in denial prevention and appeals processes when necessary.
• Support quality improvement initiatives and patient care coordination activities.

Skills

RN license

InterQual/MCG criteria

Communication

Critical thinking

Education

BSN preferred

Tools

EMR systems

Job description

Utilization Management Registered Nurse (UM RN)

Job Summary

We are seeking an experienced and detail-oriented Utilization Management Registered Nurse (UM RN) to join our hospital team. The UM RN is responsible for reviewing patient cases to ensure appropriate utilization of healthcare services, medical necessity, compliance with payer requirements, and optimal patient outcomes. This role collaborates closely with physicians, case managers, and interdisciplinary teams to support quality patient care while managing healthcare resources efficiently.

Key Responsibilities

Perform utilization review activities for inpatient and outpatient services.

Assess medical necessity, level of care, and appropriateness of admissions using established criteria such as InterQual or MCG guidelines.

Collaborate with physicians, case management, and healthcare teams regarding patient care plans and discharge planning.

Communicate with insurance providers and third-party payers to obtain authorizations and resolve coverage issues.

Monitor patient length of stay and identify opportunities to improve care efficiency.

Ensure compliance with hospital policies, federal regulations, and payer requirements.

Document utilization review findings accurately and maintain confidentiality of patient information.

Participate in denial prevention and appeals processes when necessary.

Support quality improvement initiatives and patient care coordination activities.

Qualifications

Active Registered Nurse (RN) license in the applicable state.

Bachelor of Science in Nursing (BSN) preferred.

Minimum 2–3 years of acute care hospital nursing experience required.

Prior experience in Utilization Management, Case Management, or Care Coordination preferred.

Strong knowledge of InterQual and/or MCG criteria.

Experience working with electronic medical records (EMR) systems.

Excellent communication, critical thinking, and organizational skills.