Utilization Management Nurse

Conducts clinical reviews to determine the medical necessity, appropriateness, and cost effectiveness of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries. Collaborate with healthcare providers and internal teams to promote quality, accessibility, cost effectiveness, and appropriate service levels.

Utilization Management Nurse


Job Summary

Conducts clinical reviews to determine the medical necessity, appropriateness, and cost effectiveness of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries. Promotes quality care, patient safety, regulatory compliance, and appropriate utilization of healthcare services.

Responsibilities

• Conduct and monitor clinical review cases in accordance with applicable mandates, standards, policies, and procedures.
• Document complete, accurate, and relevant clinical information.
• Screen, prioritize, and organize determination requests.
• Collaborate with healthcare providers and internal teams to promote quality, accessibility, cost effectiveness, and appropriate service levels.
• Process incoming and outgoing calls and queues efficiently within required timeframes.
• Maintain current knowledge of medical and surgical procedures, healthcare services, medications, healthcare delivery trends, policies, procedures, and contracts.
• Practice nursing within the scope of licensure and comply with URAC standards and applicable regulations.
• Make evidence-based decisions that support compliance, appropriate levels of care, and patient safety.
• Perform other duties as assigned.

Requirements

• Active, unencumbered Registered Nurse license.
• 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 is preferred.
• Bachelor of Science in Nursing is preferred.

Skill

• Proficiency with Microsoft Word, Excel, Outlook, and other computer systems.
• Ability to navigate multiple systems and perform accurate keyboarding.
• Strong critical-thinking and clinical judgment skills.
• Excellent verbal and written communication skills.
• Ability to build collaborative relationships.
• Strong attention to detail.
• Ability to interpret complex clinical documentation.
• Ability to prioritize tasks and manage workflows effectively.

Summary Qualification

• Registered Nurse with an active, unrestricted license.
• Four or more years of relevant clinical nursing experience.
• Knowledge of utilization management, medical necessity review, and healthcare services.
• Strong communication, documentation, analytical, and decision-making abilities.
• Commitment to compliance, quality care, cost effectiveness, and patient safety.

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.