Utilization Specialist, Case Management

Jobtailor; New York (NY); On-site; USD 80,000 - 110,000; Full time

Job summary

Jobtailor is seeking an experienced Utilization Review/Case Management nurse (LPN or RN) to support admission decisions, concurrent and retrospective reviews, and Medicare assessments.

You will collaborate with case managers, providers, and payers to authorize treatment plans, reviews, and discharge planning while ensuring compliance with relevant regulations. The role emphasizes documentation, quality improvement, and efficient utilization management.

Qualifications

• Active LPN or RN license in the relevant state is required.
• Minimum 2 years in Utilization Review and/or Case Management within a healthcare system or insurer.
• Knowledge of InterQual and/or MCG criteria software; certifications preferred.
• Knowledge of state and federal regulations governing health insurance and utilization management.

Responsibilities

• Perform admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and support appropriate levels of care.
• Collaborate with Case Managers, providers, and insurance companies to support treatment plans, authorization reviews, denial prevention, and discharge planning.
• Document clinical reviews, payer communications, treatment delays, avoidable days, and other case management activities in accordance with departmental and regulatory requirements.
• Maintain accurate records and databases, organize clinical information, and support concurrent and retrospective utilization reviews.
• Identify quality concerns, report potential issues, and provide guidance on case management processes and payer requirements.
• Participate in departmental initiatives, process improvement efforts, and ongoing learning to support operational excellence and high-quality patient care.

Skills

Utilization Review

Case Management

InterQual Knowledge

MCG Knowledge

Healthcare Regulations

Education

LPN/RN License

InterQual Certification

MCG Certification

Tools

InterQual Software

MCG Software

Job description

• Perform admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and support appropriate levels of care
• Collaborate with Case Managers, providers, and insurance companies to support treatment plans, authorization reviews, denial prevention, and discharge planning
• Document clinical reviews, payer communications, treatment delays, avoidable days, and other case management activities in accordance with departmental and regulatory requirements
• Maintain accurate records and databases, organize clinical information, and support concurrent and retrospective utilization reviews
• Identify quality concerns, report potential issues, and provide guidance on case management processes and payer requirements
• Participate in departmental initiatives, process improvement efforts, and ongoing learning to support operational excellence and high-quality patient care

Requirements

• Licensed Practical Nurse (LPN) or Registered Nurse (RN) with a current, active state license required
• Minimum 2 years of Utilization Review and/or Case Management experience within a healthcare system or insurance organization required
• Knowledge of InterQual software and/or MCG Medical Necessity criteria software; InterQual or MCG Certification highly preferred
• Knowledge of state and federal regulations governing health insurance coverage and utilization management

Core Competencies

Demonstrates expertise in Utilization Review and Case Management, ensuring compliance with state and federal regulations while effectively collaborating with healthcare providers and insurance companies to optimize patient care and operational efficiency.

Highest-signal resume keywords

• Licensed Practical Nurse (LPN) or Registered Nurse (RN)
• Utilization Review Experience
• Case Management Experience
• InterQual Software Knowledge
• MCG Medical Necessity Criteria Knowledge

ATS Optimization Keywords

Hard Skills

• Medical Necessity Determination
• Clinical Documentation
• Payer Communication
• Discharge Planning
• Quality Concern Identification

Soft Skills

• Collaboration
• Guidance on Case Management Processes
• Process Improvement Participation

Certifications & Qualifications

• InterQual Certification
• MCG Certification

Industry Keywords

• Healthcare System
• Insurance Organization
• State and Federal Regulations
• Utilization Management

Tools & Technologies

• InterQual Software
• MCG Medical Necessity Criteria Software