UM/UR & CDI Lead (RN)
About The Position
The UM/UR & CDI Lead conducts medical necessity, admission, continued-stay, and patient-status reviews using InterQual criteria, Medicare guidelines, and applicable payer policies. The role evaluates clinical documentation, identifies medical necessity gaps, coordinates timely payer authorizations and physician escalations, and supports accurate patient status and length-of-stay outcomes. This position develops and standardizes utilization management and review workflows, best practices, and escalation processes to improve operational efficiency and regulatory compliance. It provides leadership, training, and mentorship to hospital Care Coordination/UR staff and collaborates with physicians, case management, and hospital leadership. The role monitors program performance, establishes KPIs, prepares utilization and length-of-stay reports, supports early medical necessity review processes, and provides supplemental CDI support through concurrent reviews, documentation opportunity identification, compliant provider queries, and cross-coverage as needed. This is a full-time position in a remote home office environment. Work is generally Monday through Friday, 8:00 a.m. to 5:00 p.m.; occasional long hours and weekend work may be required. Minimal travel of up to 5% is required.
Requirements
- Bachelor’s degree in nursing (BSN) or a healthcare-related field.
- Active, unrestricted Registered Nurse (RN) license.
- 3–5 years of hospital-based Utilization Review/Utilization Management or care management experience, including medical necessity and patient-status review.
- Working knowledge of InterQual criteria, Medicare regulations, medical necessity requirements, and inpatient versus observation status.
- Demonstrated experience mentoring staff, coordinating workflows, or leading process improvement.
- Deep understanding of Medicare Part A and B, DRG assignment, and MCC/CC impact.
- Strong clinical judgment, critical thinking, problem-solving, organizational, prioritization, and multitasking skills.
- Effective leadership, mentoring, interpersonal, presentation, verbal, written, and interdisciplinary communication skills.
- Ability to self-motivate, set goals, meet deadlines, and build credible, trusted relationships with business partners.
- Professional working relationships with employees at all organizational levels.
- Advanced computer skills and proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
Nice To Haves
- Five or more years of hospital-based utilization management or utilization review experience.
- Previous UM/UR leadership, supervisory, or program development experience.
- CCM (Certified Case Manager) or ACM-RN certification.
- Experience using Epic and utilization review work queues.
- Clinical Documentation Integrity experience, including concurrent reviews and provider queries.
- CCDS or CDIP certification.
- Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC.
Responsibilities
- Conduct medical necessity, admission, continued-stay, and patient-status reviews using InterQual criteria, Medicare guidelines, and applicable payer policies.
- Evaluate clinical documentation, identify medical necessity gaps, and coordinate timely payer authorizations and physician escalations.
- Develop, implement, and standardize UM/UR workflows, best practices, and escalation processes to improve operational efficiency and regulatory compliance.
- Provide leadership, training, and mentorship to hospital Care Coordination/UR staff, promoting consistent review practices and interdisciplinary collaboration.
- Collaborate with physicians, case management, and hospital leadership to optimize utilization management, patient status accuracy, and length of stay.
- Monitor program performance, establish key performance indicators, and develop utilization and length-of-stay reports to identify improvement opportunities.
- Support the development of early medical necessity review processes, including emergency department and admission workflows.
- Provide supplemental CDI support, including concurrent reviews, identifying documentation opportunities, conducting compliant provider queries, and CDI cross-coverage as operationally needed.
Benefits
- Health coverage
- Dental coverage
- Vision coverage
- Voluntary insurance options
- 401(k) plan with employer match
- Professional development opportunities
- Paid time off
- Holiday pay
- Eligible employees may have the opportunity to participate in bonus programs, commissions, or other variable incentive plans.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
