RN Utilization Management Specialist

McLaren Health Care; Lapeer (MI); On-site; USD 85,000 - 110,000; Full time

Job summary

McLaren Health Care in Michigan is seeking a registered nurse to lead utilization management activities, ensuring medical necessity and proper documentation for inpatient and observation status. You will perform concurrent and retrospective reviews, coordinate with physicians, and help optimize hospital reimbursement.

You will document in the EMR, participate in peer reviews, support discharge planning, and mentor staff on UM processes.

Qualifications

• RN license and BSN required.
• Three years of nursing or utilization management experience.
• Certification in Case Management preferred (ACM/CCM).
• BLS certification required.

Responsibilities

• Performs concurrent and retrospective utilization management reviews and data tracking.
• Collaborates with care team to determine inpatient vs. outpatient setting based on medical necessity.
• Expedites discharge with ICM service lines.
• Screens documentation for timeliness, appropriateness, and completeness in UM processes.
• Documents in EMR: medical necessity, authorizations, avoidable days, discharge dates; uses Veracity/Optum/InterQual/Milliman.
• Facilitates peer-to-peer reviews with payer/providers.
• Participates in clinical case reviews with interdisciplinary team on continued stays/LOS outliers.
• Collaborates with providers when medical necessity is questioned per SOP.
• Keeps knowledge current on utilization review processes; assists with appeals and denials.
• Assists with training and competency development for staff.
• Performs other related duties as required.

Skills

RN license

Team collaboration

Documentation

Education

Bachelor’s degree in nursing

Certification in Case Management (ACM or CCM)

BLS Certification

Tools

Veracity

Optum

InterQual

Milliman

Job description

McLaren Health Care in Michigan is seeking a registered nurse to lead utilization management activities, ensuring medical necessity and proper documentation for inpatient and observation status. You will perform concurrent and retrospective reviews, coordinate with physicians, and help optimize hospital reimbursement.

You will document in the EMR, participate in peer reviews, support discharge planning, and mentor staff on UM processes.