Utilization Management RN

Youritrecruiter; United States; On-site; USD 85,000 - 120,000; Full time

Job summary

Youritrecruiter UM Nurse role involves conducting clinical reviews to assess medical necessity and efficiency of services requested by providers and members. It supports the health plan’s utilization management aligned with clinical guidelines and accreditation standards.

The position uses criteria such as MCG and InterQual for inpatient, outpatient, and ancillary reviews, aiming to deliver cost-effective, high-quality care and regulatory compliance.

Qualifications

• RN with an active license (state or compact).
• Minimum 3 years in utilization management within health insurance.
• Familiarity with MCG, InterQual, or CMS criteria.
• Knowledge of CMS, NCQA, URAC regulatory standards.

Responsibilities

• Conduct clinical reviews and assess medical necessity, appropriateness, and efficiency of services.
• Support UM functions in line with clinical guidelines and accreditation standards.
• Review inpatient, outpatient, and ancillary services using standard criteria.
• Ensure cost-effective, high-quality care for members.

Skills

Clinical judgment

Critical thinking

Communication skills

EMR proficiency

Education

Associate Degree in Nursing

Bachelor’s Degree in Nursing

Tools

TruCare

GuidingCare

Jiva

Job description

The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and assessing the medical necessity, appropriateness, and efficiency of healthcare services requested by providers and members. This role supports the health plan’s utilization management functions in alignment with clinical guidelines, plan benefits, regulatory requirements, and accreditation standards.

The UM Nurse ensures the delivery of cost-effective, high-quality care for members through a variety of activities including utilization review of inpatient, outpatient, and ancillary services using standardized clinical criteria such as MCG and InterQual.

Requirements

Candidates must hold an Associate Degree in Nursing and maintain an active, unrestricted Registered Nurse (RN) license in the applicable state or possess a compact license.

A minimum of three years of prior experience in utilization management within a health insurance company is required.

Strong familiarity with MCG, InterQual, or CMS criteria is essential, as is a working knowledge of UM-related regulatory and accreditation standards such as CMS, NCQA, and URAC.

The role requires advanced clinical judgment, critical thinking, and communication skills, along with proficiency in electronic medical records and utilization management systems.

Preferred qualifications include a Bachelor’s Degree in Nursing and professional certification in Case Management or Utilization Review, such as CCM, CPUR, or CPUM.

Experience using UM platforms such as TruCare, GuidingCare, Jiva, or similar systems is desirable, along with previous involvement in appeals, grievances, concurrent review, or behavioral health utilization management.

A multistate compact RN license is also preferred.