Utilization Management RN

HJ Staffing is partnering with Impresiv Health, a specialized healthcare consulting partner, to find a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN). This critical remote position supports both inpatient and outpatient utilization review, ensuring medical necessity and appropriate use of resources. This role demands strong clinical acumen, excellent documentation skills, and a solid working knowledge of Medicare Advantage regulations.

What You Will Do:

As a UM RN, you will be responsible for applying evidence-based criteria to clinical reviews and driving seamless Transitions of Care (TOC).

• Utilization Review: Conduct clinical reviews of inpatient, outpatient, and Skilled Nursing Facility (SNF) services to assess medical necessity, appropriateness, and efficiency using evidence-based guidelines, such as MCG.
• Prior Authorization: Evaluate and process prior authorization (PA) requests in a timely and accurate manner.
• Clinical Collaboration: Collaborate closely with inpatient providers to support real-time clinical decision-making and coordinate effective transitions of care.
• Care Coordination: Communicate effectively with case managers, providers, and interdisciplinary teams to coordinate care and ensure timely service delivery.
• TOC Initiatives: Participate in Transitions of Care (TOC) initiatives, with the potential to expand responsibilities in this crucial area.
• Documentation & Compliance: Maintain clear, comprehensive, and compliant documentation within internal systems (e.g., AcuityNxt and other platforms). Ensure adherence to organizational policies, Medicare Advantage rules, and state/federal regulations, including LCD/NCD policies.

What You Will Bring (Required Qualifications):

We are looking for a highly skilled and compliant RN ready to hit the ground running in a remote capacity.

• License: Active, unrestricted Registered Nurse (RN) license (state-specific or compact license as required).
• UM Experience: Minimum of 3 years of experience in Utilization Management or related clinical review settings required.
• SNF Expertise: Experience working with Skilled Nursing utilization reviews required.
• Regulatory Knowledge: Strong familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage guidelines is required.
• Prior Authorization (PA) processes required.
• Transitions of Care (TOC) background required.
• Communication: Comfort communicating with inpatient providers and clinical teams in high-pressure situations required.
• Technical Proficiency: Strong proficiency in documentation and navigating healthcare systems/platforms. Tech-savvy and adaptable to new tools/workflows in a fully remote setting.

You Will Be Successful If:

• You possess a strong understanding of both inpatient and outpatient UM and can confidently apply clinical criteria.
• You are comfortable navigating systems like AcuityNxt and quickly adapting to new technology platforms.
• You excel in remote work, managing your time effectively while consistently meeting daily review and documentation standards.
• You are a self-starter with excellent clinical judgment who can complete tasks and duties without constant direction.