Utilization Management Nurse, Inpatient, Behavioral Health, Post-Acute

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform utilization reviews of medical records, including prospective (pre-service), concurrent, and retrospective evaluations.

• Assess the medical necessity, appropriate level of care, treatment plans, timing, setting, and post-acute services.

• Suggest alternative levels of care when clinically justified.

• Conduct initial, concurrent, and discharge reviews for both inpatient and behavioral health admissions.

• Ensure the accuracy of admission status and adherence to CMS timeliness standards.

• Carry out authorization and concurrent reviews for Skilled Nursing Facilities (SNF), Long-Term Acute Care Hospitals (LTACH), Acute Rehabilitation Units (ARU), and Home Health services.

• Issue a Notice of Medicare Non-Coverage (NOMNC) when coverage criteria are not fulfilled.

• Refer cases that do not meet criteria to the Medical Director for further review and final determination.

• Prepare clinical summaries and facilitate peer-to-peer discussions.

• Manage requests for authorization reopenings as necessary.

• Monitor utilization to encourage appropriate resource use and member-centered care.

• Ensure precise, defensible documentation, complying with CMS, Medicare Advantage, and internal standards.

⛳️ Requirements

• Active RN license without restrictions and at least 4 years of clinical experience.

• Minimum of 3 years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals, ideally within a health plan, hospital, or post-acute environment.

• Knowledge of CMS regulations and Medicare Advantage requirements, or equivalent payer coverage experience.

• Experience in escalating cases that do not meet criteria, including preparing clinical summaries for physician evaluation.

• Availability to work one of the posted schedules, which includes a weekend day for most shifts.

• Preference for flexibility across multiple schedules.

• Capability to thrive in a fast-paced, constantly changing environment.

• Familiarity with AI/LLM technologies.

• Certification in InterQual.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with minimal or no premiums.

• Generous paid time off policy.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available to all employees.

• Bonus eligibility for all positions except those at the Director level and above.

• Commission eligibility applicable for Sales roles.

• Parental leave program.

• 401K retirement plan.