Utilization Management Nurse
About The Position
MEDIKO: Mission driven & committed to delivering high-quality medical care to the communities we serve. Our dedicated Healthcare Professionals find meaning, support and new opportunities to learn and grow their skills every day. It’s what sets us apart from other healthcare industries and drives our success in the correctional healthcare space. Whether you are just graduating from nursing school or bringing years of experience to your new position at MEDIKO, you will benefit from our competitive compensation, commitment to safety and exposure to the diverse healthcare needs of the clients we serve. If you’re ready to take on a role that will enrich your career and make a real impact to your community, we encourage you to APPLY TODAY to get the conversation started! The Utilization Management (UM) Nurse is responsible for reviewing and coordinating offsite specialty care, emergency department visits, and inpatient hospital services to ensure appropriate, medically necessary, and cost-effective care. This role applies nationally recognized clinical criteria, collaborates with site and hospital providers, supports discharge planning, and helps reduce avoidable admissions, complications, and delays in care. The UM Nurse also supports case review documentation, claims clarification, and reporting activities in alignment with contractual, regulatory, and organizational standards.
Requirements
- A current, valid state(s) licensure, certificate and/or credentials documenting ability to practice in applicable role, minimum LPN active license required.
- A High School diploma or GED is required.
- 1-3 years of experience in a healthcare setting, preferably in a correctional healthcare or similar environment.
- Demonstrated ability to manage time effectively, adhere to protocols, and deliver high-quality service in a fast-paced, structured environment.
- Active CPR/BLS certificate required (American Heart Association/American Red Cross guideline approved).
Nice To Haves
- An Associate’s or Bachelor's degree in Healthcare, Nursing, or a related field is preferred but not required.
- Experience in roles that involve direct patient care or administrative support in a regulated environment is preferred.
- Strong understanding of healthcare regulations, policies, and procedures as they relate to the correctional setting is an advantage.
Responsibilities
- Perform prospective, concurrent, and retrospective clinical reviews using nationally recognized, evidence-based medical necessity criteria.
- Review and validate hospital admissions, level of care, and continued stay requirements.
- Coordinate with site leadership, providers, and Regional Care Managers to ensure timely referrals and offsite care authorizations.
- Support discharge planning, transition of care, and continuity of services after hospitalization.
- Identify avoidable days, barriers to care, and opportunities for earlier intervention.
- Document all case activity clearly, accurately, and in accordance with UM standards and contractual requirements.
- Track and monitor offsite appointments, ER visits, and inpatient cases to ensure timely follow-up.
- Review offsite recommendations and assist facilities in implementing clinically appropriate treatment plans.
- Serve as a clinical resource to operations and nursing teams regarding UM processes and expectations.
- Participate in case conferences and multidisciplinary discussions as needed.
- Maintain accurate UM records and case notes within approved systems.
- Assist in preparation of UM metrics and dashboard reports.
- Identify trends related to utilization, denials, delays, and quality-of-care concerns.
- Escalate high-risk clinical concerns to the Chief Medical Officer or designee.
- Ensure UM practices comply with state regulations, Medicaid/Medicare guidance, and contract requirements.
- Provide clinical clarification for claims reviews, denials, and appeals as requested.
- Assist in verifying medical necessity documentation to support accurate payment responsibility.
- Support onboarding of facility nursing teams regarding UM workflows and expectations.
- Contribute feedback and recommendations for continuous improvement of UM processes.
- Participate in internal audits, readiness reviews, and performance improvement initiatives.
- Maintain patient confidentiality and comply with HIPAA and all applicable laws.
- Perform other duties as assigned.
Benefits
- Competitive Pay and MVP Bonus Program
- Benefits package including Medical, Dental, and Vision insurance for you and your family
- Preferred Pharmacy Network options
- MDLIVE virtual Provider telehealth options
- Wellness program
- Health Savings Accounts and Health Reimbursement Account options with company match
- Employer-paid Life Insurance Policy/AD&D, Long-Term Disability and Short-Term Disability coverage
- Optional Voluntary coverage for Life Insurance, Accident, Critical Illness, and Hospital Indemnity plans
- Paid portion of Maternity Leaves
- Employee Assistance Program
- Generous Paid Time Off (PTO) including 10 Holidays and flexible Floating Holidays
- Participation in the MEDIKO 401(k) Retirement Plan with company match
- Employee Referral Bonuses
- Tuition Reimbursement Assistance Plan
- Free Continuing Education
- Access to Perks and Discounts at nationally recognized chains, service providers and retailers
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
