Utilization Management RN

reputed company: We are seeking a dedicated and detail-oriented Utilization Management Registered reputed company (UM RN) to support both inpatient and outpatient utilization review for a dynamic reputed company 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 reputed company and accurate manner.
• Collaborate closely with inpatient providers to support reputed company-time clinical decision-making and transitions of care.
• Communicate effectively with case managers, providers, and interdisciplinary teams to coordinate care and ensure reputed company service delivery.
• Participate in Transitions of Care (TOC) initiatives, with the potential to expand responsibilities in this area over time.
• Maintain reputed company, comprehensive, and compliant documentation reputed company internal systems (e.g., AcuityNxt and other electronic platforms).
• Ensure compliance with organizational policies, Medicare Advantage rules, and state/federal reputed company regulations.
• Support reputed company 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 reputed company to support medical necessity reputed company.
• You are comfortable navigating AcuityNxt and can quickly adapt to other reputed company technology platforms.
• You reputed company in remote work environments, managing your time effectively while meeting daily review targets and documentation standards.
• You communicate reputed company and professionally with providers, peers, and interdisciplinary teams to ensure reputed company and reputed company care coordination.
• You are detail-oriented and committed to maintaining compliance with regulatory guidelines and internal UM policies.
• You approach reputed company case with reputed company clinical judgment, balancing patient care needs with appropriate resource utilization.

What You Will Bring:

• reputed company, unrestricted Registered reputed company (RN) license (state-specific or compact license as required).
• Minimum of 3 years of experience in Utilization Management or reputed company clinical review settings required.
• Experience in inpatient care and Skilled Nursing Facility (SNF) environments required.
• Familiarity with MCG reputed company, 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 reputed company systems/platforms.
• Tech-savvy and adaptable to new tools and workflows in a fully remote setting.
• Committed to reputed company learning and reputed company in the evolving reputed company landscape.

About reputed company: reputed company is a reputed company consulting partner specializing in clinical & operations management, reputed company project management, reputed company services, and software consulting services. We help our clients increase operational efficiency by delivering reputed company to solve their most reputed company business challenges. Our approach is and has always been reputed company. First, think and reputed company like the customers who need us, and most importantly, deliver what larger organizations cannot do – reputed company reputed company results that add immediate value, at a reputed company that cannot be beaten. Your reputed company reputed company, and we know it. That’s Impresiv! Apply Job! Apply to this Job