Utilization Management Nurse

ArchWell Health • Nashville, TN

1d

About The Position

Reporting to the Director of Utilization Management, the Utilization Management Nurse ensures 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.

Requirements

• Associate of Arts or Associate of Science degree in Nursing required.
• Valid, active Registered Nurse (RN) license in the state(s) of employment required.
• At least 3 years of current direct utilization management experience required.
• Strong knowledge of utilization management functions in value-based care, including data analysis, claims review, reimbursement practices, and medical records reviews.
• Thorough 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 degree of emotional intelligence and integrity, with a driven and focused work ethic.
• Desire to learn and embrace new methods, with adaptability and resilience.
• Self-starter who can think creatively and work effectively.
• Ability to build relationships and work effectively with people of varying seniorities 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.
• Work experience in an acute care facility, community-based clinic, public health department, or specialization with the senior population.
• Fluency in Spanish or another language spoken by people in the communities served.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization reviews to assess medical necessity and verify that treatment and services are appropriate and necessary by reviewing medical records and treatment plans.
• Work with healthcare providers and Medical Directors to guide approvals or requests for health plan determination reviews, as applicable, using CMS clinical guidelines and insurance policies.
• Maintain accurate and detailed records of reviews, interventions, and communications to meet health plan requirements and organizational policies.
• Analyze utilization trends and 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 identify education opportunities related to value-based care, resolve specialty gaps by market, and improve cost-effectiveness and care coordination to meet patient needs.

What This Job Offers

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