Utilization Management Reviewer

The Utilization Management Reviewer evaluates medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role involves reviewing provider requests, analyzing medical records, and making determinations based on clinical criteria, with a focus on compliance, care coordination, and efficiency.

Location: Remote

Responsibilities

• Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines
• Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care
• Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines
• Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions
• Identify and escalate complex cases requiring physician review or additional intervention
• Ensure compliance with Medicaid industry standards
• Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Requirements

• Associate’s Degree in Nursing (ASN) required; Bachelor’s Degree in Nursing (BSN) preferred
• Minimum of 3 years of diverse clinical experience as a Registered Nurse in an ICU, ED, Med-Surg, SNF, Rehabilitation, LTAC, home health care, or medical office setting
• Minimum of 2 years of experience applying evidence-based criteria (e.g., InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services
• Experience conducting utilization management reviews for a payor (e.g., Medicaid, Medicare or commercial plan) preferred

Benefits

• Flexible work solutions including remote options, hybrid work schedules
• Competitive pay
• Paid time off and holidays
• Volunteer events
• Health insurance coverage for employees and dependents on Day 1
• 401(k) plan
• Tuition reimbursement