RN Utilization Management - 37004714

RN Utilization ManagementJob SummaryThe Utilization Management Nurse performs clinical review of prior authorizations, network exceptions, benefit inquiries, inpatient medical/surgical admissions, and outpatient procedures. This role evaluates the efficiency and appropriateness of services for medical necessity using evidence-based criteria, clinical and corporate guidelines, policies, and standards, while promoting appropriate, high-quality, and cost-effective care.Responsibilities

• Work incoming and outbound calls and queues from multiple sources within mandated requirements proactively and effectively.

• Conduct and monitor clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries.

• Document all relevant and specific information and organize determination requests according to mandates and standards.

• Practice nursing within the scope of licensure and adhere to policies, procedures, regulations, accreditation standards, and state regulations.

• Make determinations based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.

• Remain current on medical and surgical procedures, products, healthcare services and drugs, and general trends in healthcare delivery.

• Maintain current knowledge of enterprise procedures, policies, and contracts relevant to utilization management.

• Collaborate with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility, and appropriate service levels.

• Promote appropriate care and quality toward cost-effective and cost-containment measures based on evidence.

• Perform other related duties as assigned.

Requirements

• Registered Nurse (RN) with an active, unrestricted license in good standing in the applicable jurisdiction.

• Minimum of four (4) years of clinical nursing experience in at least one of the following areas: medical-surgical, surgical, intensive care, or critical care.

• Bachelor s degree in Nursing preferred.

• Experience in utilization management and/or medical review preferred.

• Ability to prioritize and make sound nursing judgments using critical thinking.

• Ability to interpret complex clinical documentation.

• Ability to work independently and build collaborative relationships.

• Proficiency with basic computer skills and Microsoft Office applications, including Word, Excel, Outlook, and the ability to navigate multiple systems.

Summary Qualification

• Licensed Registered Nurse with strong clinical background in acute or critical care settings.

• Demonstrated experience in care management, utilization review, or related medical review functions.

• Proven ability to apply evidence-based criteria and clinical guidelines to determine medical necessity.

• Skilled in documentation, organization, and managing multiple concurrent cases.

• Committed to patient safety, quality of care, and cost-effective resource utilization.

Skill

• Sound judgment and critical thinking

• Analytical decision making and problem sensitivity

• Data analysis and attention to detail

• Oral and written communication

• Active listening and interpersonal relationship management

• Time management and ability to manage competing priorities

• Proficiency with Microsoft Word, Outlook, and SharePoint

• Ability to build collaborative relationships and work independently

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.