Utilization Review Nurse: Care Optimization & Compliance

American Health Communities; Franklin (TN); Remote; USD 85,000 - 105,000; Full time

Benefits offered by this job

Affordable health insurance

Paid time off

TeleDoc access

401K with company match

Employee referral program

Job summary

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., seeks a Utilization Review Nurse. You will assess the medical necessity and quality of care, conduct UM reviews, and collaborate with the Clinical Services Department to ensure compliant member care.

Requirements include an active RN license and 1+ year in utilization management, with knowledge of InterQual/MCG guidelines and Medicare rules. Remote options are not listed; location is Franklin, TN.

Qualifications

• RN license active and unrestricted.
• 1+ year in utilization management with health plan or hospital UM.
• Knowledge of Medicare regulations, CPT/ICD-10/HCPCS.
• Trained in URAC and NCQA principles, policies and procedures.
• Strong problem-solving and decision-making abilities.

Responsibilities

• Assess medical necessity, quality of care, and level of care for members.
• Identify placement settings with appropriate autonomy.
• Gather clinical data from providers and institutions.
• Apply review criteria to determine medical necessity.
• Certify cases meeting criteria; consult when not met.
• Refer cases to case management or medical consultation.
• Adhere to regulatory timeframes in UM processes.
• Notify Director of potential risk management issues.
• Perform other duties as assigned.

Skills

RN license

Communication

Critical thinking

Independent work

Education

Associates or better in Nursing

Tools

InterQual

MCG

URAC standards

NCQA principles

Job description

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., seeks a Utilization Review Nurse. You will assess the medical necessity and quality of care, conduct UM reviews, and collaborate with the Clinical Services Department to ensure compliant member care.

Requirements include an active RN license and 1+ year in utilization management, with knowledge of InterQual/MCG guidelines and Medicare rules. Remote options are not listed; location is Franklin, TN.