Utilization Management RN
About The Position
What You Will Do: Clinical Review & Medical Necessity Conducts comprehensive medical necessity reviews using evidence‑based guidelines (Milliman or InterQual) Performs initial, concurrent, and retrospective reviews to ensure accuracy and completeness of documentation supporting medical necessity. Routes cases to Physician Advisors when clinical criteria are not met or potential quality issues are identified. Care Coordination & Collaboration Partners with care managers, social workers, pharmacists, and multidisciplinary care teams to support progression‑of‑care objectives. Identifies barriers to discharge and initiates appropriate discharge planning interventions. Documentation, Compliance & Quality Ensures thorough, timely, and accurate documentation in accordance with regulatory, payer, and organizational standards. Adheres to utilization management performance metrics, including call volume, case reviews, and turnaround times. Applies strong critical‑thinking skills to evaluate complex clinical scenarios and synthesize multiple data sources into sound decisions. Technical & Professional Competencies Utilizes multiple systems, Microsoft Office applications, and clinical tools Maintains objectivity and consistency in decision‑making, leveraging clinical facts and established guidelines. Demonstrates knowledge of reimbursement methodologies, payer regulations, and managed care trends.
Requirements
- Bachelor's Degree (Relevant experience may be substituted for formal education or advanced degree)
- Registered Nurse (NY License preferred or willing to obtain upon hire)
- 4+ years Utilization Management experience
- Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form
Nice To Haves
- Behavioral Health Experience
- Medical Terminology
- Bachelor's degree in nursing
- #LI-DNI
Responsibilities
- Conducts comprehensive medical necessity reviews using evidence‑based guidelines (Milliman or InterQual)
- Performs initial, concurrent, and retrospective reviews to ensure accuracy and completeness of documentation supporting medical necessity.
- Routes cases to Physician Advisors when clinical criteria are not met or potential quality issues are identified.
- Partners with care managers, social workers, pharmacists, and multidisciplinary care teams to support progression‑of‑care objectives.
- Identifies barriers to discharge and initiates appropriate discharge planning interventions.
- Ensures thorough, timely, and accurate documentation in accordance with regulatory, payer, and organizational standards.
- Adheres to utilization management performance metrics, including call volume, case reviews, and turnaround times.
- Applies strong critical‑thinking skills to evaluate complex clinical scenarios and synthesize multiple data sources into sound decisions.
- Utilizes multiple systems, Microsoft Office applications, and clinical tools
- Maintains objectivity and consistency in decision‑making, leveraging clinical facts and established guidelines.
- Demonstrates knowledge of reimbursement methodologies, payer regulations, and managed care trends.
Benefits
- Medical, Rx, Dental & Vision Insurance
- Personal and Family Sick Time & Company Paid Holidays
- Position may be eligible for a discretionary variable incentive bonus
- Parental Leave
- 401(k) Retirement Plan
- Basic Life & Supplemental Life
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- Short-Term & Long-Term Disability
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Skills Development & Certifications
- Employee Referral Program
- Corporate Sponsored Events & Community Outreach
- Emergency Back-Up Childcare Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
