Nurse Registered Utilization Management

St. Joseph's Health•NJ, NJ

1d•$49 - $74•Onsite

About The Position

The Utilization Management Registered Nurse (UM RN) is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services in accordance with established criteria, regulatory requirements, and organizational role. The UM RN ensures optimal patient care delivery while supporting compliance, quality outcomes, and effective resource utilization. The role is responsible for the assessment of medical necessity, both for admission to the hospital as well as continued stay. This function ensures that services are not only appropriate but ensures that an authorization is obtained from the payer, if required, and that the documentation supports the care delivered in such a way that minimizes risks of denials.

Requirements

Registered Nurse (RN) license
Experience in utilization management
Knowledge of medical necessity criteria
Understanding of regulatory requirements
Ability to assess patient care needs
Documentation skills

Responsibilities

Evaluating the medical necessity, appropriateness, and efficiency of healthcare services in accordance with established criteria, regulatory requirements, and organizational role.
Ensuring optimal patient care delivery while supporting compliance, quality outcomes, and effective resource utilization.
Assessing medical necessity for admission to the hospital as well as continued stay.
Obtaining authorization from the payer, if required.
Ensuring documentation supports the care delivered to minimize risks of denials.