Registered Nurse Utilization Management

Registered Nurse Utilization Management Overview

• The Registered Nurse Utilization Management role focuses on ensuring effective healthcare service delivery through comprehensive utilization management practices.
• Collaborate with a multidisciplinary team to manage medical necessity reviews and authorization determinations.
• Utilize Milliman Care Guidelines to evaluate service appropriateness and ensure compliance with policies.
• Perform concurrent and retrospective reviews to maintain high-quality healthcare standards.
• Engage in productivity metrics and turnaround time adherence to optimize operational efficiency.
• Collaborate with consultants on denials and appeals processes to ensure patient satisfaction.
• Opportunity to work with advanced systems like DMS and QNXT for effective case management.
• Contribute to a dynamic healthcare environment with potential for temp-to-perm transition.

Registered Nurse Utilization Management Key Responsibilities & Duties

• Conduct medical necessity reviews including concurrent, prospective, and retrospective evaluations.
• Apply clinical guidelines and benefit plan designs to optimize service delivery.
• Maintain accurate records and documentation in designated medical management systems.
• Collaborate with medical consultants to discuss and review cases.
• Ensure compliance with state regulations and organizational policies.
• Identify and resolve service-related issues to enhance member outcomes.
• Participate in quality improvement initiatives and operational studies.
• Authorize vendor services using clinically proven criteria for consistent care decisions.

Registered Nurse Utilization Management Job Requirements

• Bachelor’s degree in Nursing and valid New York State Registered Nurse (RN) license.
• Minimum three years of medical/surgical experience and two years in utilization management.
• Proficiency in Milliman Care Guidelines and industry-standard utilization management practices.
• Strong communication, problem-solving, and independent decision-making skills.
• Experience with DMS and QNXT systems is highly preferred.
• Intermediate proficiency in Microsoft Office and ability to multitask effectively.
• Certification in Case Management is a plus.
• Ability to thrive in a fast-paced healthcare environment and manage competing priorities.