Utilization Management Nurse

Overview

• Serve as a Utilization Management Nurse, optimizing patient care through evidence-based practices and regulatory compliance.
• Collaborate with healthcare professionals to assess and approve medical services efficiently and effectively.
• Contribute to organizational quality improvement and compliance documentation initiatives.
• Utilize clinical criteria for decision-making and resource allocation strategies.
• Participate in utilization review processes, including appeals and claims evaluations.
• Communicate clinical decisions promptly and accurately to stakeholders.
• Support organizational objectives by summarizing data for reporting purposes.
• Work remotely while maintaining effective collaboration with the healthcare team.

Key Responsibilities & Duties

• Evaluate healthcare services for medical necessity and effectiveness using established criteria.
• Consult with the Medical Director on complex cases requiring further evaluation.
• Document clinical decisions comprehensively and ensure accurate correspondence.
• Conduct prospective, concurrent, and retrospective utilization reviews efficiently.
• Participate in appeals processes, ensuring adherence to policies and regulations.
• Summarize data for reporting purposes, supporting organizational transparency.
• Contribute to quality and performance improvement initiatives within the healthcare framework.
• Match member care needs with appropriate resources and adjust plans as necessary.

Job Requirements

• Valid, unrestricted RN license in New York State is mandatory.
• Bachelor’s Degree in Nursing (BSN) is preferred for this role.
• Minimum of 1 year of Medicare-related experience is required.
• Proficiency in evidence-based clinical decision-making processes is essential.
• Strong documentation and reporting skills in compliance with healthcare policies.
• Experience in utilization review and appeals processes is highly desirable.
• Ability to work effectively in a remote work environment while collaborating with teams.
• Commitment to supporting quality improvement initiatives and organizational goals.