Location: Remote | Must be able to work CST hours
Description:
Impresiv Health is seeking an experienced Utilization Management Registered Nurse (RN) to support clinical reviews, medical necessity determinations, and coordination of care initiatives within a health plan environment.
The Utilization Management RN will be responsible for reviewing utilization requests, assessing the appropriateness of healthcare services, and identifying and implementing care coordination opportunities for overall membership, institutionalized populations, high-risk members, and individuals with high utilization or at-risk healthcare needs.
This role functions as an active member of the Utilization Management Team, collaborating with healthcare providers and internal departments to ensure members receive appropriate, medically necessary services.
What You Will Do:
- Perform utilization reviews for outpatient and ancillary services, as well as inpatient and post-acute care services when indicated.
- Determine medical necessity and appropriateness of healthcare services using established clinical review criteria, including MCG guidelines.
- Accurately document clinical review determinations and communicate with providers and members within established timeframes.
- Identify and refer cases that do not meet established clinical criteria to the Medical Director for further review.
- Identify and escalate potential quality-of-care concerns to Medical Management leadership.
- Identify members who may benefit from Care Management programs and initiate appropriate referrals.
- Collaborate with physicians and other healthcare providers to facilitate appropriate services throughout the healthcare continuum.
- Maintain accurate data entry and comprehensive clinical documentation within designated systems.
- Communicate relevant clinical information to internal staff and interdisciplinary teams as needed.
- Participate in continuing education and ongoing professional development initiatives.
- Collaborate with other departments to support utilization management processes and organizational objectives.
- Perform additional duties as assigned.
You Will Be Successful If:
- You have a strong understanding of health plan Utilization Management processes, managed care operations, and medical necessity reviews.
- You are proficient in applying MCG guidelines to evaluate clinical appropriateness and support utilization review decisions.
- You can independently manage multiple clinical reviews while meeting established turnaround times.
- You demonstrate strong clinical judgment, logical reasoning, critical thinking, and effective decision-making.
- You possess excellent written and verbal communication skills and can effectively collaborate with physicians, providers, members, and internal teams.
- You maintain accurate, thorough, and timely clinical documentation.
- You are highly organized, detail-oriented, and capable of managing multiple priorities in a remote work environment.
- You demonstrate strong time management skills and a commitment to quality and accuracy.
What You Will Bring:
- Current, active, unrestricted Registered Nurse license
- Must have prior Utilization Management experience working within a health plan or managed care organization.
- Must have experience using MCG for medical necessity determinations and clinical utilization reviews.
- Knowledge of managed care principles and associated group benefit plans.
- Knowledge of community-based healthcare resources.
- Strong clinical assessment, logical reasoning, and decision-making skills.
- Excellent organizational, time management, communication, and documentation skills.
- Proficiency in Microsoft Office applications.
- Ability to manage multiple tasks effectively while maintaining accuracy.
Preferred Qualifications:
- Three (3) years of acute care nursing experience.
- Two (2) years of experience working with population health.
- Previous experience in discharge planning or case management.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That s Impresiv!