Utilization Review Nurse

Career Center•Franklin, TN

About The Position

The Utilization Review Nurse assesses the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The role provides clinical support to the Clinical Services Department and Medical Director to help ensure members receive appropriate medical services in compliance with medical and regulatory guidelines. American Health Plans owns and operates Institutional Special Needs Plans (I-SNPs) for seniors living in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care and reducing emergency room visits and avoidable hospitalizations. The division operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana, with planned expansion into other states in 2025.

Requirements

At least 1 year of utilization management experience with a health plan or hospital-based UM department, using InterQual or MCG.
Current, active, unrestricted Registered Nurse (RN) license.
Broad knowledge of Medicare regulations and guidance.
Training in clinical certification, utilization management, and URAC and NCQA principles, policies, and procedures.
Excellent customer service experience.
Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes.
Strong oral and written communication skills, including active listening.
Proficiency navigating multiple computer applications.
Critical-thinking, problem-solving, and decision-making skills, including the ability to make sound decisions under pressure.
Ability to work independently and as part of a team, handle multiple priorities effectively, and use independent discretion and decision-making.
Ability to work congenially with a wide variety of individuals.
Self-motivation and positive, engaging customer service skills.
Ability to maintain confidentiality and professionalism.

Nice To Haves

Clinical experience is preferred.
Current Certified Case Manager (CCM) credential is a plus.

Responsibilities

Assess the medical necessity, quality of care, level of care, and appropriateness of healthcare services for plan members.
Identify placement settings that offer members the lowest level of restriction and greatest level of autonomy based on medical necessity.
Contact requesting providers, including specialty physicians, ancillary providers, and institutions, to gather necessary clinical data.
Apply clinical review criteria, guidelines, and screens to determine the medical necessity of healthcare services against the clinical data provided.
Certify cases that meet clinical review criteria, guidelines, and/or screens.
Consult with a physician when reviews do not meet clinical review criteria, guidelines, and screens.
Refer cases to internal professionals, including case management and medical consultation, when indicated.
Adhere to accreditation, contractual, and regulatory timeframes in utilization management review processes.
Ensure the Director of Medical Management or designee is timely informed of potential risk management issues.
Maintain privacy and confidentiality of records and information concerning residents, employees, and the facility.
Encourage an atmosphere of optimism, warmth, and interest in patients’ personal and healthcare needs.
Develop and maintain collaborative relationships with providers and educate them on levels of care.
Ensure the integrity and high quality of utilization management services.
Complete required training.
Perform other duties as assigned.