RN Utilization Management Nurse

ML OUTSOURCING SERVICES PRIVATE LIMITED; United States; On-site; USD 85,000 - 110,000; Full time

Job summary

ML OUTSOURCING SERVICES PRIVATE LIMITED is seeking a remote Registered Nurse for a 6+ month engagement with extension potential. You will perform concurrent reviews, assess medical necessity, and support discharge planning for inpatient and rehabilitation cases.

The role requires 2+ years in acute care and utilization management, with familiarity with InterQual/MCG guidelines. You will document findings, educate providers, and ensure compliant care transitions while working fully remotely from

Qualifications

• Active RN license in good standing.
• 2+ years in acute care nursing.
• 2-4 years in Utilization Management, Prior Authorization or Case Management.

Responsibilities

• Perform concurrent reviews to assess health status, determine medical necessity, and support discharge planning.
• Review inpatient hospital and rehab cases for Dual Eligible (Medicare/Medicaid) members.
• Document findings and discharge plans per utilization management policies.
• Provide education to providers on utilization management processes and requirements.
• Conduct real-time concurrent reviews to ensure appropriate care and resource use.
• Apply InterQual/MCG or similar criteria to support authorization decisions.

Skills

RN license

Utilization review

Care coordination

Education

BSN or equivalent

Job description

Location: 100% Remote

Duration: 6+ months (High possibility of extension)

Responsibilities

• Perform concurrent reviews to assess members' overall health status, evaluate the appropriateness of care, determine medical necessity, and support discharge planning in accordance with utilization management guidelines.
• Review inpatient hospital and rehabilitation cases for Dual Eligible (Medicare and Medicaid) members.
• Document review findings, recommendations, and discharge plans accurately in accordance with utilization management policies and procedures.
• Support timely transitions of care and provide education to providers on utilization management processes and requirements.
• Conduct real-time (concurrent) reviews of inpatient cases to ensure appropriate care delivery and resource utilization.
• Apply medical necessity criteria, including InterQual, MCG, or similar clinical guidelines, to support authorization and care determinations

Key Requirements:

• Active RN License
• 2+ years of Acute Care Nursing experience
• Strong knowledge of medical necessity review and level of care determinations

Years of experience required:

• Minimum 2 years of clinical nursing experience
• 2-4 years of Utilization Management, Prior Authorization and Case Management
• 2+ years of acute care experience required

Education

Graduate of an accredited School of Nursing and Active Registered Nurse (RN) license

License/Certification: RN license required-Compact Licensure.

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans