UTILIZATION MANAGEMENT RN

Liberty Health; Wilmington (NC); On-site; USD 90,000 - 110,000; Full time

Job summary

Liberty Health is seeking an experienced Utilization Management RN in North Carolina to oversee UM queues, authorizations, and discharge planning. You will support clinical teams, ensure policy compliance, and prepare UM reports for leadership.

The role requires an RN license with 3–5 years in clinical settings and 1–5 years in UM or managed care, with familiarity with InterQual/MCG criteria and Medicare Advantage. A valid driver’s license and strong communication skills are essential.

Qualifications

• Licensed RN with 3–5 years of clinical experience
• Active RN license required; compact license preferred
• 1–5 years managed care utilization management experience
• Experience with health plan utilization management, initial reviews and discharge planning
• Medicare Advantage experience required
• Familiarity with InterQual or MCG criteria preferred
• Strong computer skills, attention to detail, interpersonal skills
• Must have a valid driver’s license

Responsibilities

• Manage UM queues and dashboards; ensure timely authorizations
• Assist with discharge planning and adherence to policies
• Prepare Utilization Management reports for Executive Leadership
• Review admissions and service requests against clinical guidelines
• Coordinate with care teams and documentation; support coding and denials/appeals
• Participate in on-call rotation and after-hours work as needed
• Contribute to UM meetings and written policies/workflows
• Travel to corporate office less than 10% for department meetings

Skills

Utilization Management

Case Management

Discharge Planning

Clinical Experience

InterQual/MCG Criteria

Education

Registered Nurse license

Job description

There’s no place like Liberty Health Come explore career opportunities with Liberty Health, a dynamic leader in the healthcare industry. Join us!

We Are Currently Seeking An Experienced

UTILIZATION MANAGEMENT RN

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.