Utilization Management Nurse

Overview

• Play a pivotal role in Medicare utilization management, ensuring compliance and optimizing healthcare resource allocation for enhanced patient outcomes.
• Utilize your clinical expertise to review, approve, and manage medical service requests following evidence-based guidelines.
• Collaborate with a remote team to implement best practices and drive healthcare excellence.
• Engage in quality improvement initiatives to advance organizational performance and patient care standards.
• Provide timely and transparent notifications regarding clinical decisions to ensure trust and clarity.
• Participate in utilization reviews, appeals, and claims evaluations to ensure comprehensive service assessments.
• Support data analysis efforts to identify trends and inform strategic decision-making in healthcare operations.
• Contribute to the development of policies and procedures aligned with Medicare regulations and organizational goals.

Key Responsibilities & Duties

• Conduct thorough reviews to assess medical necessity and effectiveness of healthcare services across various stages.
• Apply evidence-based criteria to evaluate service requests, ensuring optimal utilization of healthcare resources.
• Document clinical decisions comprehensively, maintaining accuracy and clarity in correspondence and records.
• Collaborate with medical directors on complex cases, providing expert clinical insights and recommendations.
• Facilitate appeals processes by preparing detailed documentation and supporting case evaluations effectively.
• Engage in organizational quality improvement initiatives to enhance service delivery and operational performance.
• Analyze healthcare data to identify trends, improve processes, and support strategic decision-making.
• Ensure compliance with Medicare regulations and organizational policies in all clinical determinations and activities.

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.