Utilization Management Nurse (RN)

Decypher; Bath Township (OH); On-site; USD 55,000 - 83,000; Full time

Benefits offered by this job

Health insurance

Professional development opportunities

Job summary

Decypher seeks a dedicated Utilization Management Nurse (RN) to ensure high standards of care, optimize resource use, and coordinate healthcare services with the Defense Health Agency. This role focuses on medical necessity reviews, data analysis, and cross-team collaboration within a mission-driven healthcare environment.

The UM Nurse will conduct comprehensive chart reviews, support case coordination, and contribute to program development.

Qualifications

• Active, unrestricted RN license (US) and BLS certification.
• 4 years discharge planning or case management for ADN holders; 2 years for BSN holders.
• Recent full-time nursing experience within the last 36 months.
• US Citizenship required.

Responsibilities

• Review clinical documentation for medical necessity and UM program alignment.
• Assist with inpatient discharge planning and coordination of follow-up care.
• Collect, analyze, and report data on resource utilization for cost containment.
• Monitor specialty care referrals and obtain required authorizations.

Skills

Analytical skills

Communication skills

Detail-oriented

RN license

Education

ADN or BSN from accredited program

Tools

Electronic Health Records (EHR) systems

Job description

Decypher is seeking a dedicated Utilization Management Nurse (RN) to help make a meaningful difference in the lives of service members, veterans, and their families. As a valued member of our healthcare team, you will play a pivotal role in ensuring high standards of care, efficient resource utilization, and the effective coordination of healthcare services in collaboration with the Defense Health Agency.

This opportunity offers the chance to contribute to the mission of supporting those who serve our country by optimizing healthcare delivery and outcomes.

The Utilization Management Nurse (RN) position involves managing and reviewing clinical documentation, working closely with medical staff to facilitate patient care, and supporting the organization's mission to deliver quality healthcare solutions. This role is ideal for professionals who possess strong analytical skills, excellent communication abilities, and a commitment to improving patient outcomes through effective utilization management and case coordination. Decypher offers a collaborative environment where your nursing expertise is respected and your work directly supports the health and readiness of America's military community.

As a Utilization Management Nurse (RN), you'll be responsible for conducting comprehensive reviews of medical records, performing medical necessity assessments, and participating in the development and implementation of utilization management programs. This position requires a high level of attention to detail, the ability to analyze complex clinical information, and the capacity to collaborate with interdisciplinary teams. You will be expected to collect and analyze data to identify patterns in healthcare resource utilization, make recommendations for process improvement, and ensure compliance with national standards and organizational goals.

Utilization Management Nurses (RNs) at Decypher are also responsible for monitoring specialty care referrals, evaluating clinical practice trends, and providing critical feedback to clinical leaders. Your contributions will support case management, discharge planning, and other key areas within the healthcare system. You will play an active role in educating staff, facilitating communication between care teams, and supporting the coordination of patient care across various settings.

Located in a vibrant area, this role provides an excellent professional environment with opportunities for career advancement and continuous learning. Decypher values diversity, inclusion, and a commitment to equal opportunity in the workplace.

Utilization Management Nurse (RN) - Summary

• Responsible for reviewing and analyzing clinical documentation to support effective utilization management and resource allocation.
• Collaborates with the Defense Health Agency to optimize healthcare delivery for service members, veterans, and their families.
• Works as part of a multidisciplinary team to ensure quality care and compliance with national standards.
• Participates in the ongoing development of utilization management programs and process improvements.

Duties & Responsibilities

• Assist with inpatient discharge planning, including patient and family interviews, safety assessments, and coordination of follow-up care and equipment.
• Develop, implement, and monitor a comprehensive Utilization Management (UM) program aligned with organizational and Defense Health Agency goals.
• Collect, analyze, and report data on healthcare resource use, identifying opportunities for cost containment and improved efficiency.
• Monitor and manage specialty care referrals, ensuring appropriateness and authorization for medical procedures, laboratory, radiology, and pharmacy services.
• Evaluate clinical practice patterns, provide feedback to healthcare leaders, and participate in peer reviews.
• Identify cases suitable for Disease Management, Case Management, and Discharge Planning, and refer as appropriate.
• Participate in clinical meetings, working groups, and care coordination activities.
• Educate staff on utilization management principles and processes.
• Perform medical necessity reviews and communicate findings to appropriate clinical leadership.
• Navigate electronic health records and managed care systems to support referral management and care coordination.
• Authorize referrals and validate eligibility for supplemental health programs as designated.
• Ensure accuracy and completeness of clinical documentation and electronic records.
• Perform other duties as assigned to support organizational goals.

Salary & Benefits

• Competitive hourly compensation with additional Health & Welfare benefits if applicable.
• Comprehensive benefits package, including health insurance and professional development opportunities.
• Regular weekday schedule with structured hours for work-life balance.

Qualifications & Requirements

• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) from an accredited program.
• Active, unrestricted Registered Nurse license.
• Basic Life Support (BLS) certification.
• Minimum of 4 years of experience in discharge planning or case management for ADN holders, or 2 years for BSN holders.
• Recent full-time nursing experience within the last 36 months.
• U.S. Citizenship required.
• Ability to sit or stand for extended periods and occasionally lift up to 10-15 pounds.

Ideal Candidate Snapshot

• Detail-oriented and analytical, with a keen ability to review and interpret complex clinical information.
• Excellent verbal and written communication skills for effective collaboration and documentation.
• Strong organizational skills with the ability to manage multiple tasks and priorities.
• Experience working in utilization management, case management, or discharge planning.
• Commitment to quality care, patient advocacy, and continuous professional development.
• Proficiency with electronic health record systems and healthcare data analysis.

Other Relevant Information

• Join a mission-driven organization dedicated to supporting military personnel and their families through high-quality healthcare management.
• Decypher is an equal opportunity and affirmative action employer committed to a diverse and inclusive workforce (M/F/D/V).
• Opportunities for ongoing training, professional growth, and career advancement are available.