Utilization Management Nurse

A company is looking for a Utilization Management Nurse to review and monitor healthcare service utilization for members.

Key Responsibilities

Conducts concurrent and retrospective reviews of facility and home health services to improve quality outcomes and decrease costs

Determines observational vs acute inpatient status as part of the prior authorization process

Engages with providers for proactive discharge and transition planning and prepares necessary documentation for compliance

Required Qualifications

Minimum 2 years of clinical experience as an RN, LPN, or LVN required

Minimum 1 year of managed care or equivalent health plan experience preferred

Experience in health plan utilization management and facility concurrent review required

Active unrestricted Nursing license required

Experience with InterQual or MCG authorization criteria preferred