Utilization Management, Registered Nurse (RN)

Key Responsibilities:

• Perform medical necessity reviews for prior authorization and concurrent review across acute inpatient, post-acute, and outpatient services.
• Apply CMS Medicare guidelines, NCD/LCD policies, and MCG criteria to support evidence-based determinations.
• Manage cases end-to-end from prior authorization through concurrent review and discharge, ensuring smooth care transitions.

Collaboration & Compliance:

• Collaborate with providers and facilities to obtain clinical information and support effective care coordination.
• Ensure compliance with CMS turnaround times and regulatory requirements for all utilization management activities.
• Participate in Quality Assurance activities, including case audits and peer reviews, to maintain accuracy and consistency.

Required Qualifications & Environment:

• Must hold a current and valid Compact Registered Nurse (RN) license and have experience in Utilization Management.
• Requires at least 1 year of experience performing medical necessity reviews using CMS Medicare criteria.
• Must be comfortable working in a remote, fast-paced, and data-driven environment with established productivity standards.