Utilization Management Registered Nurse (UM RN)

The Utilization Management Registered Nurse is responsible for conducting utilization management reviews to ensure members receive medically necessary, appropriate, and cost-effective care. The UM RN performs initial and concurrent reviews across inpatient, observation, skilled nursing, acute rehabilitation, LTACH, home health, and other applicable services. 

The UM RN applies MCG/InterQual criteria, health plan guidelines, CMS regulations, and organizational policies to evaluate medical necessity, level of care, length of stay, and discharge needs. The UM RN collaborates with Medical Directors, providers, facilities, members, families, and interdisciplinary teams to promote quality outcomes and timely transitions of care. 

The UM RN also supports quality gap closure, care coordination, quality improvement initiatives, NCQA accreditation requirements, and departmental performance goals, while maintaining established productivity, quality, documentation, compliance, and turnaround-time KPIs. 

ESSENTIAL DUTIES AND RESPONSIBILITIES 

• Performs initial and concurrent utilization reviews for inpatient, observation, SNF, acute rehabilitation, LTACH, home health, and other services as assigned. 

• Determines medical necessity and appropriateness of care using MCG/InterQual, health plan guidelines, CMS regulations, NCQA standards, and departmental policies. 

• Evaluates level of care, length of stay, treatment plans, and discharge needs and identifies opportunities for appropriate transitions to lower levels of care. 

• Refers cases not meeting established criteria to the Medical Director and communicates determinations to appropriate parties. 

• Collaborates with providers, facilities, Medical Directors, case managers, social workers, and other interdisciplinary team members to facilitate timely and appropriate discharge planning. 

• Identifies barriers to discharge and coordinates medically necessary services, authorizations, referrals, and transitions of care. 

• Identifies members requiring ongoing case management or additional clinical support and makes appropriate referrals. 

• Supports quality initiatives and quality gap closure by identifying opportunities related to preventive care, chronic disease management, screenings, follow-up care, medication adherence, and other applicable quality measures. 

• Communicates identified quality gaps to appropriate clinical teams and assists with interventions and closure when applicable. 

• Maintains established UM KPIs, including productivity, turnaround time, documentation accuracy, quality, compliance, and service-level expectations. 

• Supports the organization's efforts to achieve and maintain NCQA accreditation standards by adhering to applicable policies, workflows, documentation requirements, utilization management standards, and audit requirements. 

• Participates in NCQA, health plan, regulatory, and internal audits and ensures assigned UM activities and documentation meet applicable accreditation and regulatory standards. 

• Identifies and escalates potential quality-of-care or quality-of-service concerns and participates in quality assurance and improvement activities. 

• Reviews utilization data and reports, including admissions, length of stay, avoidable days, readmissions, and other assigned metrics, and identifies opportunities for improvement. 

• Participates in UM committees, staff meetings, education, special projects, and process improvement initiatives. 

• Maintains accurate, timely, and compliant documentation and protects member confidentiality in accordance with HIPAA and organizational policies. 

• Maintains current knowledge of utilization management, Medicare Advantage, managed care, NCQA standards, regulatory requirements, quality initiatives, and clinical guidelines. 

• Performs other duties as assigned. 

KNOWLEDGE, SKILLS AND ABILITIES 

• Knowledge of utilization management and medical necessity criteria, including MCG/InterQual. 

• Knowledge of Medicare Advantage, HMO, managed care, and post-acute care. 

• Knowledge of NCQA accreditation standards and regulatory requirements preferred. 

• Knowledge of quality measures and quality gap closure. 

• Strong clinical assessment, critical thinking, communication, and documentation skills. 

• Ability to manage multiple priorities and meet productivity, quality, compliance, and turnaround-time expectations. 

• Proficiency with electronic medical records; Epic/Tapestry experience preferred. 

• Ability to work effectively in a multidisciplinary and metrics-driven environment. 

EDUCATION AND/OR CERTIFICATION/LICENSURE 

• Associate/Diploma or Bachelor's Degree in Nursing from an accredited nursing program. 

• Current, unrestricted Registered Nurse (RN) license. 

• CCM or ACM certification preferred. 

EXPERIENCE 

• Minimum of two (2) years of clinical nursing experience, preferably in an acute care setting. 

• Two (2) years of experience in Utilization Management, concurrent review, or Case Management in a health plan or hospital setting preferred. 

• Experience with Medicare Advantage and HMO populations preferred. 

• Experience with NCQA accreditation, quality improvement, HEDIS/Stars, or quality gap closure preferred.