Job Summary
The Utilization Management Nurse supports the effective coordination and management of healthcare services by reviewing clinical information, determining medical necessity, facilitating appropriate resource utilization, and ensuring compliance with regulatory and accreditation requirements. This role promotes quality, cost-effective care while maintaining accurate documentation and collaborating with internal and external stakeholders to optimize member outcomes.
Key Responsibilities
- Conduct utilization reviews and clinical assessments to evaluate the medical necessity, appropriateness, and efficiency of healthcare services.
- Apply evidence-based criteria and clinical expertise to support benefit and utilization management decisions.
- Review medical records, treatment plans, and supporting documentation to ensure compliance with clinical guidelines, organizational policies, and regulatory requirements.
- Develop, coordinate, and support care plans in collaboration with healthcare providers, multidisciplinary teams, and payers.
- Prepare, audit, and manage approval and denial letters in accordance with established policies and regulatory standards.
- Promote effective utilization management practices through consultation, education, and collaboration with healthcare professionals and stakeholders.
- Support care coordination efforts to improve member outcomes and ensure appropriate access to healthcare services.
- Communicate effectively with providers, members, and internal teams regarding utilization management decisions and processes.
- Maintain complete, accurate, and timely documentation to meet risk management, regulatory, and accreditation requirements.
- Provide guidance and coaching to nursing staff and other healthcare professionals on utilization management principles and best practices.
- Contribute to the development and implementation of utilization management policies, procedures, and quality improvement initiatives.
- Promote the quality, effectiveness, and efficiency of healthcare services across the continuum of care.
Required Qualifications
- Active Registered Nurse (RN) license.
- 3-5 years of relevant clinical, case management, utilization management, or healthcare experience.
- Knowledge of medical terminology and healthcare delivery systems.
- Strong problem-solving and critical-thinking skills.
- Effective decision-making abilities with demonstrated clinical judgment.
- Proficiency with technology and digital tools used in healthcare environments.
- Ability to analyze the costs and benefits of alternative approaches and recommend appropriate solutions.
- Strong interpersonal and communication skills with the ability to interact professionally with providers, members, and community partners.
- Ability to maintain confidentiality and handle sensitive information ethically and responsibly.
- Ability to work effectively within diverse clinical and cultural environments.
- Must be available to work a Thursday-Sunday schedule from 9:00 AM to 8:00 PM Eastern Time.
Preferred Qualifications
- Experience in utilization management, care management, managed care, or health plan operations.
- Knowledge of regulatory, accreditation, and quality standards related to utilization management.
- Experience reviewing medical necessity criteria and healthcare benefits.
Education
- Bachelor's degree in Nursing, Healthcare Administration, or a related healthcare field preferred.
- Equivalent specialized training, certification, or relevant professional experience may be considered in lieu of a degree.
Anticipated Weekly Hours: 40
Time Type: Full time
Pay Range
The typical pay range for this role is
$26.01 - $68.55