Utilization Review Nurse

Leave Your Mark; Michigan; Remote; USD 70,000 - 100,000; Full time

Benefits offered by this job

401(k)

Paid vacation time

Career growth opportunities

Competitive compensation

Job summary

Leave Your Mark is seeking a Registered Nurse for Utilization Review to support a Michigan health plan client from a home-based setting. The role focuses on prospective, concurrent, and retrospective reviews to determine medical necessity, level of care, and length of stay for various services.

You will apply clinical judgment and evidence-based criteria, work with the medical director when needed, and ensure documentation meets accreditation and regulatory standards.

Qualifications

• Bachelor of Science in Nursing (BSN) preferred; ADN with relevant experience considered.
• Ability to maintain licensure and, where applicable, eligibility for multi-state licensure.
• Proficient with using technology including MS Office Applications, PDF, and Office.

Responsibilities

• Review, research, and authorize requests for elective, direct, and urgent services using approved criteria.
• Coordinate with medical staff to identify alternatives per client protocols.
• Evaluate documentation against MCG/InterQual criteria and CMS guidance.
• Document all review activity and determinations in the UR system.
• Support discharge-planning needs and coordinate referrals with care management.
• Communicate with providers and facilities to obtain records and convey approvals.
• Maintain confidentiality and HIPAA compliance and participate in IRR where required.

Skills

Critical thinking

Team player

Communication skills

Multitasking

Education

BSN preferred

ADN with experience considered

Tools

MS Office

PDF workflows

Job description

The Registered Nurse, Utilization Review is a U.S.-licensed clinician who performs utilization management and review for a Michigan health plan client under our client's domestic onshore service offering. Working within the client's systems and evidence-based clinical criteria, the nurse conducts prospective, concurrent, and retrospective reviews to determine medical necessity, appropriate level and setting of care, and length of stay for inpatient, outpatient, ambulatory, and ancillary services. The role requires working knowledge of case management practice. May also support care coordination activities, including discharge planning support and warm hand-offs per organization’s process.

The nurse applies clinical judgment, communication skills, and independent critical thinking to interpret criteria, policies, referring requests to the medical director as per the health plan policy and criteria. The Registered Nurse Utilization Review ensures all documentation is in line with accreditation, regulatory standards to support the coordination, documentation, and communication of medical-necessity determinations.

UM Review for the Commercial, Medicare, Medicaid managed and ASO/self-funded populations and lines of business using the client’s medical policy, criterial and guidelines such as MCG and InterQual, CMS NCD and LCD guidelines, Michigan state requirements, all within URAC and NCQA aligned standards to support compliance. Review types can include prospective and prior authorizations, concurrent and continued stay reviews, retrospective or post service review. The Registered Nurse Utilization management will also be required to perform intake screenings and case set up, support the lack of information process and follow-up. Case turnaround times must be met and include expedited and urgent case types. Review types can also include Post acute reviews (SNF< LTACH, IRF), home health, outpatient therapies such as OT/PT, radiology, imaging, DME, and other in-scope services.

In the Registered Nurse, Utilization Review role, you will be responsible for:

• Review, research, and authorize requests for elective, direct, ancillary, urgent, and emergency services, applying approved clinical criteria to determine medical necessity, level of care, setting, and length of stay.
• Contact appropriate medical and support personnel to identify and recommend alternatives according to established client protocols.
• Evaluate clinical documentation against nationally recognized criteria (MCG/InterQual), CMS guidance, and client medical policy; approve/certify when criteria are met and route cases that do not meet criteria to the client's Medical Director for determination.
• Document all review activity, clinical rationale, and determinations completely and accurately in the client's UM system, in accordance with client policy, regulatory timeframes, and accreditation standards.
• Support coordination of care by identifying discharge-planning needs, communicating with appropriate internal and external parties, and facilitating referrals/hand-offs to the plan's care management team for members who screen as higher risk.
• Apply working knowledge of case management practice to recognize members who may benefit from care management, transitions-of-care support, or community resources, build and establish care plans and coordinate care accordingly.
• Communicate professionally with providers, facilities, members, and client staff to obtain records, clarify requests, and convey approval/certification information; verify identity and consent before disclosing protected health information (PHI).
• Identify and document potential quality-of-care or consumer-safety concerns and route them to the appropriate area for resolution.
• Meet or exceed established productivity, turnaround-time (TAT), and quality/clinical-decision accuracy targets, and participate in inter-rater reliability (IRR) assessments and calibration.
• Maintain strict confidentiality and comply with HIPAA, fraud-waste-and-abuse controls, the Code of Business Ethics and Conduct, and all applicable client, state, and federal requirements.
• Completely required onboarding, client certification, continuing education, & license/certification-renewal requirements; assist with precepting and peer documentation review as requested.

Qualification Requirements:

• Bachelor of Science in Nursing (BSN) preferred; ADN with relevant experience considered.
• Current active, unrestricted RN license in any state with the ability to obtain the State of Michigan Nursing License (exclusions: Northern Mariana Island, Guam, Puerto Rico)
• Ability to maintain licensure and, where applicable, eligibility for compact/multistate licensure and additional single-state licenses without restriction.
• Strong team player who possesses strong critical thinking skills, and ability to work independently, while escalating appropriately
• Working knowledge of case management practice and coordination of care / discharge planning processes.
• Experience applying MCG and/or InterQual® criteria preferred.
• Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management and utilization review etc.,
• Capable of working within tight deadlines, detail-oriented and highly organized. Effective communication skills (verbal and written).
• Proficient with using technology including ability to multitask across multiple environments including MS Office Applications, PDF, Office
• Able to work from home in a distraction free, private office space
• Internet to support minimum upload and download speeds,
• Ability to support up to 10% travel as necessary to include Shearwater Nashville location and client location

Preferred Qualifications:

• Current, active, unrestricted Registered Nurse (RN) license in the State of Michigan, in good standing strongly preferred
• One (1) + year of health-plan or managed-care experience is strongly preferred.
• Medicare, Medicaid, and/or Commercial experience preferred.
• Experience applying MCG and/or InterQual® criteria preferred.
• Previous global, matrixed healthcare organization experience/background preferred

Employee Benefits:

• A competitive compensation structure
• 401(k)
• Paid vacation time
• The opportunity to build your career in a rewarding and unforgettable way