Utilization Management RN — Elevate Care Efficiency

Clearlink Partners; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Clearlink Partners is seeking a utilization management professional to determine medical necessity using established guidelines. You will perform 15-30 reviews daily, covering inpatient and outpatient services, and collaborate with Medical Directors to ensure timely access to care.

The role requires RN licensure, strong experience in managed care, and a track record in process improvement and payment integrity within a dynamic healthcare environment.

Qualifications

• Current unencumbered Compact RN license.
• Experience with SIU investigations and reviews.
• 2+ years utilization management experience.
• 5+ years acute clinical experience.
• 5+ years managed care exposure across multiple lines of business.
• HMO and risk contracting experience preferred.
• In-depth knowledge of medical practices and insurance benefit structures.
• Proficient in Microsoft Office.

Responsibilities

• Determine appropriateness of services using medical guidelines and criteria (MCG, InterQual).
• Perform 15-30 reviews per day.
• Review inpatient admissions for medical necessity and appropriateness.
• Review outpatient surgeries and ancillary services.
• Document all determinations and communicate with providers/members.
• Collaborate with Medical Directors on referrals and complex cases.
• Ensure timely access to medically necessary services.
• Follow regulatory requirements and maintain compliance.

Skills

Utilization Management

SIU Investigations

Process Improvement

Payment Integrity

Managed Care

MCG/InterQual

Medical Necessity

Communication Skills

Customer Service

Organization

Teamwork

Microsoft Office

Education

Compact RN license (unencumbered)

5+ years acute clinical experience

Tools

Microsoft Office

Job description

Clearlink Partners is seeking a utilization management professional to determine medical necessity using established guidelines. You will perform 15-30 reviews daily, covering inpatient and outpatient services, and collaborate with Medical Directors to ensure timely access to care.

The role requires RN licensure, strong experience in managed care, and a track record in process improvement and payment integrity within a dynamic healthcare environment.