Utilization Management - RN

Bickham Services Unlimited, LLC•Sunnyvale, CA

1d•Onsite

About The Position

Our client is seeking an experienced Concurrent Review Registered Nurse (RN) to join its Utilization Management team. In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care while collaborating with physicians, hospitals, and interdisciplinary teams to ensure members receive appropriate, cost-effective, and evidence-based care. This position is ideal for an RN with strong acute care experience and a background in managed care, utilization management, or case management.

Requirements

Active Registered Nurse (RN) license with the ability to obtain licensure in multiple states.
Graduate of an accredited School of Nursing.
Minimum 4 years of clinical nursing experience.
Minimum 2 years of managed care or HMO experience.
Experience performing medical necessity reviews using evidence-based clinical guidelines.
Strong knowledge of: Concurrent Review, Utilization Management, Discharge Planning, Transitions of Care
Experience applying: InterQual, MCG, CMS Guidelines
Experience working with medical management software and Microsoft Office.
Excellent communication, critical thinking, and organizational skills.
Must have experience with Medicare Advantage.
Must have experience with Concurrent Review, Inpatient, Utilization Management, Discharge Planning, and Transitions of Care

Nice To Haves

Bachelor of Science in Nursing (BSN).
Emergency Department (ER) experience.
Intensive Care Unit (ICU) experience.
Case Management experience.
Utilization Management experience within a health plan or managed care organization.
Experience working directly with hospitals, physicians, and provider networks.

Responsibilities

Perform concurrent, prior authorization, and retrospective utilization reviews.
Evaluate medical necessity using InterQual, MCG, CMS, LCD/NCD, and health plan guidelines.
Coordinate discharge planning and transitions of care with providers and healthcare facilities.
Collaborate with physicians, hospital staff, specialists, and internal care management teams.
Request and review additional clinical documentation when necessary.
Escalate complex medical necessity cases to the Medical Director.
Educate providers on utilization management policies and review criteria.
Document all reviews and clinical decisions accurately within medical management systems.
Identify care gaps and support quality improvement initiatives.
Serve as a clinical resource for internal teams.