Registered Nurse – Utilization Management (RN UM) - 25-34348

NavitsPartners • Orono, ME

4d

About The Position

We are seeking an experienced Registered Nurse – Utilization Management (RN UM) to support utilization review and care coordination activities within a healthcare setting. This role focuses on ensuring appropriate use of healthcare services, compliance with regulatory requirements, and coordination of care across the continuum. The RN UM will collaborate with physicians, care teams, and administrative staff to evaluate medical necessity, manage authorizations, and support quality and cost-effective patient care.

Requirements

• Active Registered Nurse (RN) license in the practicing state
• Prior experience in Utilization Management, Case Management, or Clinical Review
• Strong knowledge of medical necessity criteria, utilization review processes, and payer guidelines
• Experience with electronic medical records and utilization management systems
• Excellent communication, critical thinking, and organizational skills
• Ability to work independently and collaboratively within a multidisciplinary team

Nice To Haves

• Experience in acute care, long-term care, or managed care settings
• Familiarity with InterQual®, MCG®, or similar utilization review criteria

Responsibilities

• Conduct utilization review to ensure medical necessity and appropriate level of care
• Review clinical documentation for compliance with payer, state, and federal guidelines
• Coordinate prior authorizations, concurrent reviews, and discharge planning support
• Collaborate with physicians and interdisciplinary teams regarding care plans and utilization decisions
• Communicate with payers and internal departments regarding coverage determinations
• Identify opportunities to improve care coordination and reduce avoidable utilization
• Maintain accurate, timely, and compliant documentation in electronic systems
• Participate in on-call rotation as required
• Ensure compliance with facility policies, CMS, and accreditation standards

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed