Utilization Management Nurse

ArchWell Health • Nashville, TN

22h

About The Position

Reporting to the Director of Utilization Management, the Utilization Management Nurse helps ensure patients receive appropriate, cost-effective care by reviewing and evaluating medical services, treatments, and procedures. The role identifies trends and opportunities to educate and collaborate with healthcare providers, patients, and specialists to optimize resource utilization and improve patient outcomes.

The nurse conducts prospective, concurrent, and retrospective utilization reviews, works with providers and Medical Directors on health plan determination reviews, maintains detailed review records, analyzes utilization trends, and educates providers and patients on appropriate levels of care. The position also collaborates with Network and specialists to support value-based care, address specialty gaps by market, and improve cost-effectiveness and coordination of care.

Requirements

• Associate of Arts or Associate of Science degree in Nursing.
• Valid, active Registered Nurse (RN) license in the state or states of employment.
• At least 3 years of current, direct utilization management experience.
• Strong knowledge of utilization management in value-based care, including data analysis, claims review, reimbursement practices, and medical records review.
• In-depth knowledge of evidence-based practice, legal rules and regulations, and healthcare best practices.
• Ability to leverage business and organizational knowledge within and across functional areas.
• High emotional intelligence and integrity, with a driven and focused work ethic.
• Desire to learn and embrace new methods, with the ability to adapt and demonstrate resilience.
• Ability to work independently, think creatively, and work effectively.
• Ability to build relationships and work effectively with people of different seniority levels and diverse populations.
• Excellent critical reasoning, decision-making, and problem-solving skills to make informed decisions and support effective resource utilization while maintaining quality patient care.
• Willingness and ability to travel up to 20%.
• Proficient PC skills.

Nice To Haves

• Bachelor of Arts or Bachelor of Science degree in Nursing (BSN) or Healthcare Administration.
• Experience working in an acute care facility, community-based clinic, public health department, or specialization with the senior population.
• Fluency in Spanish or other languages spoken by people in the communities served.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews for medical necessity by reviewing medical records and treatment plans.
• Collaborate with healthcare providers and Medical Directors and provide guidance on approvals or health plan determination review requests, using CMS clinical guidelines and insurance policies.
• Maintain accurate and detailed records of reviews, interventions, and communications to support adherence to health plan requirements and organizational policies.
• Analyze utilization trends to assess progress toward organizational goals.
• Educate healthcare providers and patients about appropriate levels of care, service criteria, and guidelines.
• Collaborate with Network and specialists to educate on value-based care, resolve specialty gaps by market, improve cost-effectiveness, and coordinate care to meet patient needs.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree