Utilization Management Registered Nurse (UM RN)

Duly Health and Care; Downers Grove (IL); On-site; USD 68,000 - 101,000; Full time

Benefits offered by this job

Medical, dental, vision benefits

Mental health benefit

Life and disability insurance

Tuition reimbursement

401(k) match

Volunteer time off

Community engagement

Parental leave and adoption/surrogacy

Job summary

Duly Health and Care is seeking a dedicated Utilization Management Registered Nurse to perform initial and concurrent reviews across inpatient, SNF, home health, and other services. You will apply MCG/InterQual criteria, CMS guidelines, and NCQA standards to determine medical necessity and appropriate level of care.

Collaborating with Medical Directors, providers, case managers, and care teams, you will drive timely transitions of care, discharge planning, and quality improvement initiatives

Qualifications

• Knowledge of utilizationmanagement and medical necessity criteria, including MCG/InterQual.
• Knowledge of Medicare Advantage, HMO, managed care, and post-acute care.
• Knowledge of NCQA accreditation standards and regulatory requirements preferred.
• Knowledge of quality measures and quality gap closure.
• Strong clinical assessment, critical thinking, communication, and documentation skills.
• Ability to manage multiple priorities and meet productivity, quality, compliance, and turnaround-time expectations.
• Proficiencywith electronic medical records; Epic/Tapestry experience preferred.
• Ability to work effectively in a multidisciplinary andmetrics-driven environment.

Responsibilities

• Performs initial and concurrentutilizationreviews for inpatient, observation, SNF, acute rehabilitation, LTACH, home health, and other services as assigned.
• Determinesmedical necessity and appropriateness of care using MCG/InterQual, health plan guidelines, CMS regulations, NCQA standards, and departmental policies.
• Evaluates level of care, length of stay, treatment plans, and discharge needs andidentifiesopportunities forappropriate transitionsto lower levels of care.
• Referscases not meeting established criteria to the Medical Director and communicates determinations toappropriate parties.
• Collaborates with providers, facilities, Medical Directors, case managers, social workers, and other interdisciplinary team members tofacilitatetimelyandappropriate dischargeplanning.
• Identifiesbarriers to discharge andcoordinatesmedically necessary services, authorizations, referrals, and transitions of care.
• Identifiesmembers requiring ongoing case management oradditionalclinical support andmakesappropriate referrals.
• Supportsquality initiatives and quality gap closurebyidentifyingopportunities related to preventive care, chronic disease management, screenings, follow-up care, medication adherence, and other applicable quality measures.

Skills

Clinical assessment

Critical thinking

Documentation

Communication

Education

Associate/Diploma or Bachelor0s Degree in Nursing

RN license

Tools

Epic/Tapestry

Job description

At Duly Health and Care , you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do.

With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Benefits:

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

The Utilization Management Registered Nurseis responsible forconductingutilizationmanagement reviews to ensure members receive medically necessary,appropriate, and cost-effective care. The UM RN performs initial and concurrent reviews across inpatient, observation, skilled nursing, acute rehabilitation, LTACH, home health, and other applicable services.

The UM RN appliesMCG/InterQual criteria, health plan guidelines, CMS regulations, and organizational policies to evaluate medical necessity, level of care, length of stay, and discharge needs. The UM RN collaborates with Medical Directors, providers, facilities, members, families, and interdisciplinary teams to promote quality outcomes andtimelytransitions of care.

The UM RN also supports quality gap closure, care coordination, quality improvement initiatives, NCQA accreditation requirements, and departmental performance goals, whilemaintainingestablished productivity, quality, documentation, compliance, and turnaround-time KPIs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Performs initial and concurrentutilizationreviews for inpatient, observation, SNF, acute rehabilitation, LTACH, home health, and other services as assigned.
• Determinesmedical necessity and appropriateness of care using MCG/InterQual, health plan guidelines, CMS regulations, NCQA standards, and departmental policies.
• Evaluates level of care, length of stay, treatment plans, and discharge needs andidentifiesopportunities forappropriate transitionsto lower levels of care.
• Referscases not meeting established criteria to the Medical Director and communicates determinations toappropriate parties.
• Collaborates with providers, facilities, Medical Directors, case managers, social workers, and other interdisciplinary team members tofacilitatetimelyandappropriate dischargeplanning.
• Identifiesbarriers to discharge andcoordinatesmedically necessary services, authorizations, referrals, and transitions of care.
• Identifiesmembers requiring ongoing case management oradditionalclinical support andmakesappropriate referrals.
Supportsquality initiatives and quality gap closurebyidentifyingopportunities related to preventive care, chronic disease management, screenings, follow-up care, medication adherence, and other applicable quality measures.
• Communicates identified quality gaps to appropriate clinical teams andassistswith interventions and closure when applicable.
• Maintains establishedUM KPIs, including productivity, turnaround time, documentation accuracy, quality, compliance, and service-level expectations.
• Supports the organization’s efforts toachieve and maintain NCQA accreditation standardsby adhering to applicable policies, workflows, documentation requirements,utilizationmanagement standards, and audit requirements.
• Participates in NCQA, health plan, regulatory, and internal audits and ensures assigned UM activities and documentation meet applicable accreditation and regulatory standards.
• Identifiesand escalates potential quality-of-care or quality-of-service concerns andparticipatesin quality assurance and improvement activities.
• Reviewsutilizationdata and reports, including admissions, length of stay, avoidable days, readmissions, and other assigned metrics, andidentifiesopportunities for improvement.
• Participatesin UM committees, staff meetings, education, special projects, and process improvement initiatives.
• Maintainsaccurate,timely, and compliant documentation and protects member confidentialityin accordance withHIPAA and organizational policies.
• Maintains current knowledge ofutilizationmanagement, Medicare Advantage, managed care, NCQA standards, regulatory requirements, quality initiatives, and clinical guidelines.
• Performs other duties as assigned.

KNOWLEDGE,SKILLSAND ABILITIES

• Knowledge ofutilizationmanagement and medical necessity criteria, including MCG/InterQual.
• Knowledge of Medicare Advantage, HMO, managed care, and post-acute care.
• Knowledge of NCQA accreditation standards and regulatory requirements preferred.
• Knowledge of quality measures and quality gap closure.
• Strong clinical assessment, critical thinking, communication, and documentation skills.
• Ability to manage multiple priorities and meet productivity, quality, compliance, and turnaround-time expectations.
• Proficiencywith electronic medical records; Epic/Tapestry experience preferred.
• Ability to work effectively in a multidisciplinary andmetrics-driven environment.

EDUCATION AND/OR CERTIFICATION/LICENSURE

• Associate/Diploma orBachelor’s Degree in Nursingfrom an accredited nursing program.
• Current, unrestricted Registered Nurse (RN) license.
• CCM or ACM certification preferred.

EXPERIENCE

• Minimum of two (2) years of clinical nursing experience, preferably in an acute care setting.
• Two (2) years of experience in Utilization Management, concurrent review, or Case Management in a health plan or hospital setting preferred.
• Experience with Medicare Advantage and HMO populations preferred.
• Experience with NCQA accreditation, quality improvement, HEDIS/Stars, or quality gap closure preferred.

If you are committed to putting our patients first and helping shape the future of care, you belong at Duly.

The compensation for this role includes a base pay range of $67,953.60- $101K with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.