Utilization Management Specialist

Logan Health

6d • $38 - $54 • Remote

About The Position

Logan Health is seeking a Utilization Management Specialist to review admissions across its health system and determine appropriate patient admission status. The role is suited to an RN or Social Worker with acute-care hospital experience, strong communication skills, and the ability to collaborate with physicians, case management, and insurance partners. The specialist supports patient outcomes, appropriate resource use, and accurate documentation in a mission-driven care environment.

This is a fully remote position, and applicants must currently reside in Montana. The schedule is full-time, 40 hours per week, across four 10-hour variable shifts. Morning shifts typically begin around 7:00 a.m.; afternoon shifts begin around 10:00 a.m. The position includes a Saturday and Sunday rotation every fourth weekend and rotating holiday coverage. Logan Health operates 24 hours a day, seven days a week, and schedules may be adjusted to meet position and organizational needs.

The specialist coordinates patient-status identification using validated criteria; reviews inpatient and observation admissions and patient stays; collaborates with stakeholders on medical necessity and status questions; supports payer authorizations, peer-to-peer reviews, denials, appeals, audits, and inquiries; and identifies and addresses barriers to timely reviews and compliance. The role also contributes to reporting, education, process improvement, departmental standards, staff orientation, and documentation and referral of utilization-management, quality, and risk concerns.

The position requires a current Montana RN license or a multistate compact license authorizing practice in Montana, or a bachelor's degree in Social Work; an associate degree is also required, with a bachelor's preferred. At least five years of acute-care hospital experience is required. CCM certification, inpatient utilization review or UM experience, and knowledge of specified Medicare, Medicaid, and review-program topics are preferred.

Requirements

• Meet at least one of the following: current Montana RN license or multistate compact license authorizing nursing practice in Montana; or a bachelor's degree in Social Work.
• Associate degree required; bachelor's degree preferred.
• Minimum of five years of acute-care hospital experience.
• Excellent interpersonal skills and ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
• Excellent verbal and written communication skills, including the ability to communicate effectively with varied audiences.
• Strong computer literacy, analytical thinking, clinical judgment, attention to detail, and ability to manage multiple priorities in a fast-paced environment.
• Must currently reside in Montana.

Nice To Haves

• CCM certification.
• Prior experience as an inpatient utilization review nurse or UM specialist.
• Knowledge of Medicare and Medicaid UM regulations, the Medicare Inpatient Only List, RAC, QIO, MAC, and denial management.
• Bachelor's degree.

Responsibilities

• Review daily inpatient and observation admissions across the Logan Health system.
• Evaluate physician documentation and patient data to determine appropriate admission status.
• Reassess patients throughout their stay to confirm continued level-of-care criteria are met.
• Coordinate correct patient-status identification using validated criteria.
• Complete short-stay work-queue reviews and track and trend results for reporting and education.
• Collaborate with the physician UM Advisor, case management, insurance partners, and other stakeholders on authorizations, medical necessity, and patient-status questions.
• Assist with scheduling and coordinating peer-to-peer physician reviews.
• Communicate with providers, nurses, and other stakeholders to support accurate documentation and smooth care transitions.
• Identify and address issues that could delay reviews, impede UM functions, or affect compliance; facilitate resolution and monitor issues until resolved.
• Use electronic medical records to support documentation, review, and reporting.
• Perform concurrent and retrospective reviews as directed by assigned leadership.
• Assist with appeal letters for insurance denials, audit activities, and responses to payer inquiries.
• Seek consultation from appropriate disciplines or departments to expedite care and facilitate timely, accurate documentation and clinical reviews.
• Participate in developing, implementing, teaching, evaluating, and revising departmental UM standards, and orient new department staff on UM.
• Document UM, quality, and risk concerns and refer them to appropriate departments for follow-up.
• Identify opportunities for process and system improvement and initiate or lead performance initiatives as indicated.
• Work independently while collaborating with the interdisciplinary team.

Benefits

• Affordable medical benefits package.
• 401(k) with immediate employer match.
• Logan Health Fitness Center membership discount.
• Supportive, mission-driven nursing culture focused on quality, compassion, and person-centered care.
• Four-day work week.

What This Job Offers

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