Utilization Management Nurse, Senior
About The Position
The Utilization Management team independently manages complex utilization and retrospective clinical reviews across multiple lines of business, assessing medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements while supporting clinical consistency, process improvement, quality, timeliness, and appropriate escalation of high-risk cases. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Requirements
- Must be a licensed RN.
- Must have at least 3 years of experience in utilization management.
- Must have experience with Medicare and Medicaid regulations.
- Must have strong analytical and problem-solving skills.
- Must have excellent communication and interpersonal skills.
- Must be proficient in Microsoft Office Suite.
Nice To Haves
- Experience with case management.
- Experience with managed care.
- Experience with electronic health records.
Responsibilities
- Independently manages complex utilization and retrospective clinical reviews across multiple lines of business.
- Assesses medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements.
- Supports clinical consistency, process improvement, quality, and timeliness.
- Manages appropriate escalation of high-risk cases.
Benefits
- Health insurance
- Dental insurance
- Vision insurance
- 401k
- Paid time off
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
