Utilization Management Nurse

Overview

• Contribute to impactful utilization management processes, ensuring compliance with Medicare standards and optimizing healthcare resource allocation.
• Collaborate remotely with a dedicated team to enhance patient outcomes through evidence-based practices.
• Utilize clinical expertise to review and approve medical service requests, adhering to established guidelines.
• Engage in quality improvement initiatives, driving organizational excellence and performance enhancement.
• Provide timely and detailed notifications regarding clinical decisions to ensure transparency and trust.
• Participate in utilization reviews, appeals, and claims processes for comprehensive service evaluation.
• Support data analysis and reporting efforts to inform strategic decision-making and operational improvements.

Key Responsibilities & Duties

• Conduct prospective, concurrent, and retrospective reviews to assess medical necessity and service effectiveness.
• Apply evidence-based criteria to evaluate healthcare services, ensuring optimal resource utilization.
• Document clinical decisions comprehensively, maintaining accuracy in correspondence and case files.
• Collaborate with medical directors on complex service reviews, providing expert clinical insights.
• Facilitate appeals processes by preparing detailed documentation and supporting case evaluations.
• Engage in organizational quality improvement initiatives to enhance service delivery and performance.
• Analyze data to identify trends and inform strategic healthcare decisions.
• Ensure compliance with regulatory requirements and organizational policies in all clinical determinations.

Job Requirements

• Active RN license in New York State, unrestricted and in good standing.
• Bachelor’s Degree in Nursing (BSN) or equivalent educational background preferred.
• Minimum of 1 year of experience in Medicare utilization management required.
• Proficiency in evidence-based clinical decision-making and utilization review processes.
• Strong documentation, reporting, and analytical skills to support operational excellence.
• Ability to work effectively in a remote environment, demonstrating self-motivation and collaboration.
• Commitment to quality improvement and performance enhancement in healthcare services.
• Familiarity with Medicare regulations and standards for service delivery.