Value-Based Utilization Management RN

ArchWell Health; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

ArchWell Health is seeking an Utilization Management Nurse to ensure patients receive appropriate, cost-effective care. You will review medical services for medical necessity, collaborate with providers and Medical Directors, and maintain detailed records to meet health plan requirements.

The role focuses on education, quality outcomes, and coordinating with networks to optimize resource use. You will evaluate trends, educate on value-based care, and support across markets, traveling up to 20%

Qualifications

• AA/AS in Nursing required; BSN preferred.
• Active RN license in state(s) of employment required.
• Minimum of 3 years in utilization management.
• Experience in acute care facility, community clinic, or senior population settings preferred.
• Spanish language ability or other languages common in service areas is desirable but not required.

Responsibilities

• Conducts prospective, concurrent, and retrospective utilization reviews for medical necessity by reviewing medical records and treatment plans.
• Collaborates with healthcare providers and Medical Directors to provide guidance on approvals or requests for health plan determinations.
• Maintains accurate records of reviews, interventions, and communications to ensure compliance with health plan requirements.
• Analyzes utilization trends to support organizational goals.
• Educates providers and patients on appropriate levels of care and service criteria.
• Identifies opportunities to educate on value-based care and improve cost-effectiveness across markets.

Skills

Utilization management

Data analysis

Medical records reviews

CMS guidelines

Healthcare reimbursement

Stakeholder collaboration

Emotional intelligence

Problem-solving

Travel availability

Education

AA/AS in Nursing

BSN preferred

Active RN license

Job description

ArchWell Health is seeking an Utilization Management Nurse to ensure patients receive appropriate, cost-effective care. You will review medical services for medical necessity, collaborate with providers and Medical Directors, and maintain detailed records to meet health plan requirements.

The role focuses on education, quality outcomes, and coordinating with networks to optimize resource use. You will evaluate trends, educate on value-based care, and support across markets, traveling up to 20%