Utilization Management Nurse, Senior

Your Role

The Utilization Management team independently manages complex utilization and retrospective clinical reviews across multiple lines of business, assessing medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements while supporting clinical consistency, process improvement, quality, timeliness, and appropriate escalation of high-risk cases.

Responsibilities

In this role, you will

• Independently manages complex prospective, concurrent, and retrospective utilization reviews across multiple lines of business
• Conducts retrospective clinical reviews of claims for medical necessity, coding accuracy, medical policy, and contract compliance
• Serves as a clinical subject matter resource to peers by providing guidance on criteria application, documentation, and processes
• Evaluates treatment plans, lengths of stay, and discharge planning to ensure quality, cost effective utilization of services
• Identifies overpayment, third party liability, and coordination of benefits opportunities and initiates appropriate follow up
• Supports process improvement efforts to enhance clinical consistency, efficiency, and regulatory compliance
• Escalates complex or high risk cases to leadership or Medical Directors with clear clinical rationale
• Works with minimal supervision while maintaining accountability for quality, accuracy, and timeliness
• Ability to work evenings and weekends as part of rotating on-call schedule

Qualifications

Your Knowledge and Experience

• Associate Degree in Nursing required
• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience managed care environment or clinical setting
• Maintain active, unrestricted RN License in assigned states or the ability to obtain required state (in addition to primary state license) RN license within 90 days of hire

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.