Utilization Management RN
About The Position
The Utilization Management Nurse, National Medicaid Clinical Operations is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for inpatient services. This role ensures that all requests meet medical necessity criteria and comply with health plan policies and regulatory requirements. The RN Review Nurse works closely with healthcare providers, interdisciplinary teams, and nonclinical staff to facilitate timely and appropriate care for members. This role operates autonomously within their scope of practice, making independent clinical decisions. This role will report directly to the Manager, Utilization Management.
Requirements
- Licensed Registered Nurse in Illinois, with no disciplinary action (or willing to obtain Illinois licensure upon hire)
- 3+ years of clinical nursing experience
- Experience with Medicaid policies and procedures
- Proficiency in healthcare software and electronic medical records (EMR) systems
- Previous experience in utilization management
- Comprehensive knowledge of Microsoft Word, Outlook and Excel
- Self-provided internet service must meet at least a download speed of 25 Mbps and an upload speed of 10 Mbps; wireless, wired cable or DSL connection is suggested.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Nice To Haves
- Bachelor’s degree
- Certification in Case Management (CCM) or Utilization Review (UR)
- Experience with Medicaid and Medicare policies and procedures
- Knowledge of payer policies, insurance companies and government health programs
Responsibilities
- Conduct comprehensive clinical reviews of prior authorization requests to determine medical necessity and benefit eligibility
- Apply advanced evidence-based clinical guidelines in review decisions
- Ensure compliance with accreditation, state, and federal regulations
- Communicate with healthcare providers to obtain necessary clinical information and clarify requests
- Coordinate with medical directors and interdisciplinary teams to support decision-making
- Serve as a liaison between clinicians, internal departments, and members
- Document all review findings and decisions in clinical documentation systems
- Ensure timely and accurate documentation of prior authorization determinations
- Support reporting initiatives and provide data for performance improvement projects
- Implement quality assurance measures to ensure accuracy and consistency in prior authorization decisions
- Conduct regular audits and reviews to maintain high standards of service
- Identify process improvement opportunities and contribute to performance improvement projects
- Educate providers and staff on prior authorization policies, criteria, and review processes
- Provide mentorship and feedback to nonclinical staff and peers to enhance workflow efficiency
- Stay current with clinical best practices and regulatory changes
Benefits
- medical, dental and vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
