Utilization Management Nurse

Job Summary

A company is looking for a Utilization Management Nurse (PST Time Zone).

Key Responsibilities

• Conducts concurrent and retrospective reviews of facility and home health services, ensuring quality care and cost management
• Determines observational vs acute inpatient status during the hospital prior authorization process
• Engages with providers for proactive discharge and transition planning, while maintaining accurate records of communications

Required Qualifications

• Minimum 2 years of clinical experience as RN, LPN/LVN required
• Minimum 1 year of managed care or equivalent health plan experience preferred
• Experience in health plan utilization management and facility concurrent review required
• Active unrestricted Nursing license required
• Experience with InterQual or MCG authorization criteria preferred