Role Overview: The Utilization Management (UM) Nurse conducts medical necessity reviews, ensures appropriate care levels, and facilitates safe transitions for a targeted patient population. They review all new admissions, observation cases, and ongoing assessments using clinical criteria and collaborate with physicians and the care team.
Key Responsibilities:
- Perform clinical reviews and determine the most appropriate level of care based on documentation, criteria, and clinical judgment.
- Obtain timely authorizations from payers, document activities accurately in EPIC, and resolve discrepancies related to authorization, ALOS, and billing.
- Communicate with providers and payors to address denials, ensure compliance with regulations, and support continuous improvement initiatives.
- Monitor post-discharge accounts, evaluate clinical documentation, and escalate issues through the established chain of command.
Qualifications & Skills:
- Minimum 3 years of strong clinical practice/experience; RN license (single-state or multi-state compact) required.
- Associates or Bachelor’s Nursing degree preferred.
- Knowledge of case management processes, excellent communication skills, and strong organizational abilities.
- Proficient with screening criteria, clinical documentation, and computer systems.
Additional Information: The role is part-time on weekends, with responsibilities focused on clinical review, documentation, payer interactions, and quality improvement, supporting safe, efficient patient care and billing processes.