This role is for a Utilization Management Nurse (UM) Coordinator responsible for conducting 24/7 medical necessity reviews, utilizing clinical criteria and documentation to determine appropriate levels of care.
Key duties include managing hospital admissions, concurrent reviews, and post-discharge accounts to ensure timely authorization, accurate documentation, and compliance with payer regulations. The UM nurse collaborates with physicians, payers, and care teams to resolve discrepancies, overturn denials, and facilitate safe patient transitions.
Qualifications require a minimum of 3 years of clinical experience, an active RN license (single or multi-state), and BLS certification.
Skills needed include strong knowledge of case management, excellent communication, organizational abilities, and proficiency with screening criteria and clinical data analysis. The role involves building trusting relationships with physicians and teams to ensure efficient patient care and reimbursement processes.
Additional responsibilities encompass professional development, mentoring, and ensuring compliance with healthcare policies. This position offers flexible shifts and is essential for supporting quality patient care and operational efficiency.