Utilization Management Registered Nurse

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

📋 Description

• Perform clinical evaluations of inpatient, outpatient, and Skilled Nursing Facility (SNF) services to determine medical necessity, suitability, and efficiency using evidence-based criteria (e.g., MCG).

• Review and handle prior authorization (PA) requests promptly and in compliance with regulations.

• Work in partnership with inpatient providers and case managers to facilitate Transitions of Care (TOC) and discharge planning.

• Clearly communicate with interdisciplinary teams to ensure coordinated and effective delivery of care.

• Keep accurate and comprehensive records in systems such as AcuityNxt and other electronic platforms.

• Ensure adherence to Medicare Advantage, state, and federal healthcare regulations.

• Participate in process improvement initiatives aimed at enhancing overall Utilization Management (UM) effectiveness and efficiency.

⛳️ Requirements

• Current, unrestricted RN license (either state-specific or compact).

• Minimum of 3 years of experience in Utilization Management or relevant clinical review roles.

• Demonstrated experience with Skilled Nursing Facility (SNF) utilization reviews.

• Strong understanding of MCG criteria, LCD/NCD policies, and Medicare Advantage regulations.

• Previous involvement in prior authorization (PA) and Transitions of Care (TOC) processes.

• Exceptional clinical communication skills and confidence in interacting with inpatient providers.

• High attention to detail, accuracy in documentation, and a focus on compliance.

• Proficient in technology with the ability to swiftly adapt to healthcare systems and remote working tools.

🏝️ Benefits

• Fully Remote position – enjoy a work-life balance while aiding patients across the continuum of care.

• Collaborative, mission-oriented healthcare setting.

• Opportunity to grow into Transitions of Care (TOC) initiatives and process enhancement.

• Competitive salary and benefits package.