Utilization Management Nurse

Conducts clinical reviews to determine the medical necessity, appropriateness, quality, and cost-effectiveness of inpatient and outpatient services. Maintain current knowledge of medical and surgical procedures, healthcare services, products, medications, and healthcare delivery trends.

Utilization Management Nurse


Job Summary

Conducts clinical reviews to determine the medical necessity, appropriateness, quality, and cost-effectiveness of inpatient and outpatient services. Ensures compliance with regulatory requirements, contractual standards, utilization review guidelines, and patient safety practices.

Responsibilities

• Review inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgical requests for medical necessity.
• Document relevant clinical information and organize determination requests according to applicable mandates and standards.
• Promote appropriate care, quality outcomes, accessibility, and cost-effective treatment.
• Collaborate with healthcare providers and internal teams to support appropriate service levels and care coordination.
• Process incoming and outgoing calls and queues efficiently within required timeframes.
• Practice nursing within the scope of licensure and follow applicable policies, procedures, regulations, and utilization review standards.
• Make objective, evidence-based decisions that support compliance, appropriate levels of care, and patient safety.
• Maintain current knowledge of medical and surgical procedures, healthcare services, products, medications, and healthcare delivery trends.
• Perform other duties as assigned.

Requirements

• Active, unrestricted Registered Nurse license in the applicable state.
• At least four years of clinical nursing experience in medical-surgical, surgical, intensive care, or critical care nursing.
• Experience in utilization management or medical review preferred.
• Bachelor of Science in Nursing preferred.

Skill

• Proficiency with Microsoft Word, Excel, Outlook, keyboarding, and multiple computer systems.
• Strong critical-thinking skills and the ability to make sound nursing judgments.
• Excellent verbal and written communication skills.
• Ability to build effective, collaborative relationships.
• Strong attention to detail.
• Ability to interpret complex clinical and medical documentation.

Summary Qualification

• Licensed Registered Nurse with substantial clinical nursing experience.
• Knowledge of utilization management, medical necessity review, healthcare regulations, and evidence-based care.
• Ability to manage multiple requests, prioritize work, and meet required timeframes.
• Commitment to quality care, patient safety, regulatory compliance, and cost-effective healthcare delivery.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.