Advanced RN Analyst - Utilization Management Quality & Training

We are seeking a Michigan RN Analyst - Utilization Management Quality & Training. This is 100% remote.

The Advanced RN Analyst is an experienced Utilization Management subject matter expert responsible for quality oversight, auditing, clinical analysis, policy/procedure development, process improvement, and operational support within the Clinical Review department.

The primary focus is Medicare Utilization Management involving acute inpatient hospital admission determinations. This role conducts quality audits of RN utilization reviewers, applies InterQual criteria, evaluates compliance with regulatory requirements, analyzes audit results, and identifies opportunities for process improvement.

The position also develops training materials and provides education related to UM processes, InterQual criteria, policies, procedures, and systems. Formal training responsibilities will increase as the individual gains knowledge of department operations.

Required Qualifications

• Michigan RN license - current/unrestricted

• 3-5+ years - Utilization Management recent acute inpatient hospital admission review, including Medicare.

• 3-5+ years - InterQual hands-on experience

• 3-5+ years - Quality reviews - clinical staff review of cases

• Audit, analysis and reporting - internal/external

• Documentation - developing/updating policies, procedures, training materials, and job aids.

• Technical

• Microsoft - Word, Excel (formulas/pivot tables), PowerPoint, SharePoint, Teams

• AI tools

• Multiple systems/applications, virtual desktop environments, dual monitors.

• Strong knowledge of CMS/regulatory requirements.

• Nursing Diploma or Associate Degree in Nursing (ADN). Bachelor of Science in Nursing (BSN) preferred.

Preferred Qualifications

• CCM or other relevant clinical certification.
• Formal training/education experience.
• Experience with process improvement, project management, and system enhancements.

Key Responsibilities

• Conduct quality audits of Medicare RN acute inpatient admission determinations.
• Review utilization management decisions for accuracy, consistency, medical necessity, and adherence to InterQual and regulatory requirements.
• Conduct internal and external audits; analyze findings, identify trends, and prepare reports.
• Provide clinical feedback and subject matter expertise based on audit results.
• Develop, update, and maintain policies, procedures, training materials, job aids, and other educational resources.
• Support process improvement initiatives and the development, testing, and implementation of new systems and workflows.
• Interpret and implement changes to InterQual criteria, CMS requirements, policies, and procedures.
• Develop and deliver training related to UM processes, criteria, policies, procedures, and systems.
• Assist with onboarding and mentoring of clinical review staff.
• Partner with leadership and subject matter experts on projects and operational initiatives.
• Manage multiple assignments and priorities while maintaining accuracy and meeting deadlines.

Why work with us? We are a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work with us you"ll have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! We are an EOE, all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. https://www.optechus.com/eeo_self_identification/