Utilization Management Nurse

Job Summary:

The Concurrent Utilization Review (UR) Nurse is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan. This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.

Key Responsibilities:

1. Concurrent Review & Case Assessment

• Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
• Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays.
• Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.

2. Collaboration with Medical Director

• Review and escalate complex or borderline cases to the Medical Director for further assessment.
• Provide the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for continued care or level-of-care decisions.
• Collaborate with the Medical Director to develop treatment recommendations and resolve discrepancies in care.

3. Authorization & Payer Communication

• Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
• Communicate with healthcare providers to request additional documentation or clarify treatment plans.
• Ensure timely approvals or denials of requested services per the health plan’s benefit structure and clinical guidelines.
• Escalate cases to the Medical Director or higher clinical authority when necessary.

4. Care Coordination & Discharge Planning Support

• Work closely with case managers, social workers, and care teams to facilitate seamless care transitions.
• Participate in interdisciplinary discussions to address complex cases and ensure members receive appropriate care.
• Identify and escalate discharge barriers to support timely and effective discharge planning.
• Assist in transitioning patients from inpatient to outpatient or post-acute care settings.

5. Compliance & Documentation

• Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies.
• Maintain accurate, up-to-date documentation of all concurrent review activities, including authorizations, denials, escalations, and Medical Director reviews.
• Support quality improvement initiatives by tracking utilization trends and identifying resource optimization opportunities.

6. Education & Collaboration

• Educate providers and staff on health plan clinical guidelines, medical necessity criteria, and authorization processes.
• Provide guidance on escalating complex cases to the Medical Director.
• Stay updated on industry trends, regulatory changes, and best practices in utilization management.
• Participate in interdisciplinary team meetings and case conferences.

Qualifications:

• Education: Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required; BSN preferred.
• Experience:
  • Minimum of 4 years or more of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
  • Experience in a managed care setting with medical necessity reviews is strongly preferred.
• Certifications:
  • Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
  • Additional clinical nursing or case management certifications are a plus.
• Skills:
  • Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria.
  • Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members.
  • Strong analytical skills and attention to detail in reviewing clinical documentation.
  • Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite.

Performance Metrics:

1. Timeliness of Reviews & Authorizations

• Percentage of concurrent reviews completed within the required turnaround time (TAT).
• Average response time for provider inquiries and authorization requests.

2. Compliance & Accuracy

• Adherence to regulatory and accreditation requirements (e.g., CMS, NCQA, URAC).
• Accuracy in applying medical necessity guidelines and compliance with internal policies.
• Results of internal audits and quality assurance reviews.

3. Case Escalation Efficiency

• Percentage of complex cases escalated to the Medical Director in a timely manner.
• Turnaround time for resolving escalated cases.

4. Utilization & Cost Management

• Reduction in unnecessary inpatient days through appropriate level-of-care determinations.
• Cost savings achieved through effective utilization management and alternative care recommendations.
• Reduction in readmission rates related to premature discharges.

Work Environment:

• Corporate office preferred / remote may be considered
• Collaborative environment requiring frequent communication with clinical and administrative teams.