RN Utilization Management: Drive Evidence-Based Care

Harris Jones Staffing Recruiting Llc; City of Long Beach (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

The Registered Nurse (RN) will join our Utilization Management team to perform concurrent reviews, prior authorizations, and medical necessity reviews. You will collaborate with physicians, hospitals, and interdisciplinary teams to ensure appropriate, cost-effective, evidence-based care in a fast-paced setting.

Ideal candidates have a strong acute care background and at least 4 years of clinical nursing, with 2 years in managed care or HMO; Medicare Advantage experience is preferred.

Qualifications

• Active RN license; ability to obtain multi-state licensure if needed.
• 4+ years of clinical nursing experience.
• 2+ years of managed care or HMO experience; Medicare Advantage experience required.
• Direct experience in concurrent/inpatient utilization management, discharge planning, and transitions of care.

Responsibilities

• Perform concurrent, prior authorization, and retrospective utilization reviews.
• Evaluate medical necessity using InterQual, MCG, CMS guidelines.
• Coordinate discharge planning and transitions of care with providers and facilities.
• Collaborate with physicians, hospital staff, and care management teams; escalate complex cases to Medical Director.
• Educate providers on utilization management policies and review criteria.
• Document reviews and decisions accurately; identify care gaps for quality improvement.

Skills

RN license

Managed care experience

InterQual guidelines

Discharge planning

Documentation skills

Communication skills

Education

BSN preferred

Accredited School of Nursing

Tools

Medical management software

Microsoft Office

Job description

The Registered Nurse (RN) will join our Utilization Management team to perform concurrent reviews, prior authorizations, and medical necessity reviews. You will collaborate with physicians, hospitals, and interdisciplinary teams to ensure appropriate, cost-effective, evidence-based care in a fast-paced setting.

Ideal candidates have a strong acute care background and at least 4 years of clinical nursing, with 2 years in managed care or HMO; Medicare Advantage experience is preferred.