Utilization Management RN
Description: We are seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to support both inpatient and outpatient utilization review for a dynamic healthcare organization. This role requires strong clinical acumen, excellent documentation skills, and a solid understanding of Transitions of Care (TOC). Candidates should bring prior inpatient and Skilled Nursing Facility (SNF) experience, familiarity with MCG guidelines, and a working knowledge of Medicare Advantage regulations, including LCD/NCD policies. What You Will Do:
- Conduct clinical reviews of inpatient, outpatient, and SNF services to assess medical necessity, appropriateness, and efficiency using evidence-based guidelines (e.g., MCG).
- Evaluate and process prior authorization (PA) requests in a timely and accurate manner.
- Collaborate closely with inpatient providers to support real-time clinical decision-making and transitions of care.
- Communicate effectively with case managers, providers, and interdisciplinary teams to coordinate care and ensure timely service delivery.
- Participate in Transitions of Care (TOC) initiatives, with the potential to expand responsibilities in this area over time.
- Maintain clear, comprehensive, and compliant documentation within internal systems (e.g., AcuityNxt and other electronic platforms).
- Ensure compliance with organizational policies, Medicare Advantage rules, and state/federal healthcare regulations.
- Support continuous improvement by sharing insights and participating in process optimization efforts.
You Will Be Successful If:
- You have a strong understanding of both inpatient and outpatient utilization review and can confidently apply clinical criteria to support medical necessity decisions.
- You are comfortable navigating AcuityNxt and can quickly adapt to other healthcare technology platforms.
- You excel in remote work environments, managing your time effectively while meeting daily review targets and documentation standards.
- You communicate clearly and professionally with providers, peers, and interdisciplinary teams to ensure collaborative and timely care coordination.
- You are detail-oriented and committed to maintaining compliance with regulatory guidelines and internal UM policies.
- You approach each case with sound clinical judgment, balancing patient care needs with appropriate resource utilization.
What You Will Bring:
- Active, unrestricted Registered Nurse (RN) license (state-specific or compact license as required).
- Minimum of 3 years of experience in Utilization Management or related clinical review settings required.
- Experience in inpatient care and Skilled Nursing Facility (SNF) environments required.
- Familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage guidelines is required.
- Prior experience in prior authorization (PA) processes required.
- Background in Transitions of Care (TOC) initiatives required.
- Comfortable communicating with inpatient providers and clinical teams in high-pressure situations required.
- Strong proficiency in documentation and navigating healthcare systems/platforms.
- Tech-savvy and adaptable to new tools and workflows in a fully remote setting.
- Committed to continuous learning and growth in the evolving healthcare landscape.
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! Apply Job! Apply to this Job