UTILIZATION MANAGEMENT RN

Liberty Health; Raleigh (NC); On-site; USD 75,000 - 110,000; Full time

Job summary

Liberty Health is seeking an experienced Utilization Management RN to oversee day-to-day UM queues, dashboards, and member care coordination in a hospital or health plan setting.

The role focuses on timely authorizations, discharge planning, and adherence to medical necessity guidelines to ensure high-quality, cost-effective care. Strong communication and problem-solving skills are essential.

Qualifications

• Licensed RN with 3–5 years of clinical experience and active license.
• 1–5 years managed care utilization management experience, preferably with a health plan.
• Experience with Medicare Advantage and utilization management criteria (InterQual/MCG) required.

Responsibilities

• Manage UM queues, dashboards, and member care coordination.
• Ensure timely authorizations and discharge planning per policies.
• Monitor medical necessity guidelines and report to leadership.
• Assist with UM reports for executive review.
• Participate in on-call rotation and occasional after-hours work.

Skills

RN license

UM management

Medicare Advantage

InterQual/MCG criteria

Communication skills

Detail-oriented

Problem-solving

Education

Registered Nurse license

Tools

InterQual

MCG criteria

EHR systems

Job description

UTILIZATION MANAGEMENT RN

There’s no place like Liberty Health

Come explore career opportunities with Liberty Health, a dynamic leader in the healthcare industry. Join us!

JOB SUMMARY:

• Day-to-day management of Utilization Management queues, dashboards, members, ensuring all Utilization Management activities, which include authorization timeliness, discharge planning, adherence to policies and procedures to ensure high quality and cost-effective utilization management services.
• Ability to work decision letters timely and accurately
• Quality monitoring focusing on medical necessity guidelines and discharge planning opportunities to lower levels of care
• Assist the Director of Utilization Management with the Utilization Management Reports to be reviewed by Executive Leadership.
• Ability to contribute to the UM team to ensure compliant execution of UM program
• Review admissions and service requests for the following:
  • Authorization requests to ensure appropriate care for members and within clinical guidelines
  • Monitor members both inpatient/outpatient - provide updates to Director of Utilization Management and the clinical care teams
  • Recommend more appropriate care if required
• Assess and coordinate discharge planning with Care Team.
• Assist co-workers with issues related to coding, medical records/documentation, pre-certification reimbursement and claim denials/appeals.
• Use critical thinking and problem-solving to navigate through the complexities of a member’s health conditions while maintaining coverage within the program guidelines.
• Ability to focus on interventions for improvement
• Provides appropriate responses to providers regarding UM questions or direct these questions to the Director of Utilization Management
• Monitors utilization management queues and dashboards, assuring compliance with reporting and turnaround times.
• Participates in the interdisciplinary approach to support continuity of care
• Participates in the Case Management processes and assists with the development of case management programs
• Ability to participate and contribute with the written policies and procedures and workflows
• Ability to participate in the On-Call rotation to ensure timeliness is maintained
• Ability to work occasional after hours to ensure timeliness is maintained.
• Contribute to and attend UM meetings and UM huddles.
• Other duties as assigned
• Less than 10% travel to the corporate office for Department meetings

JOB REQUIREMENTS:

• Licensed Registered Nurse credentialed from an accredited school/college with 3-5 years of clinical experience
• Maintain Active Registered Nurse License, (Compact, RN preferred)
• 1-5 years managed care Utilization Management experience (preferably with a Health Plan)
• Demonstrated experience in health plan utilization management, initial reviews, facility concurrent review discharge planning, and case management required.
• Medicare Advantage experience required
• Experience with InterQual or MCG authorization criteria preferred.
• Excellent computer skills and the ability to learn new systems are required.
• Strong attention to detail, organizational skills, and interpersonal skills are required.
• Demonstrated ability to problem-solve and manage professional relationships.
• Healthcare industry knowledge
• Excellent listening, verbal, written and interpersonal communication skills.
• High level of professionalism and confidentiality, with a strong customer focus.
• Can adapt well to operational needs with excellent follow-up skills.
• Must be self-motivated, with a work ethic of dedication and the discipline to work independently.
• Must have a valid driver’s license.
• Proven ability to communicate concisely and confidently with all staff levels. Clearly communicates instructions to remote users.

Background checks/drug-free workplace.

EOE.