We are seeking an experienced Utilization Management Nurse (RN or LVN) to support inpatient clinical reviews, discharge planning, and care coordination for a healthcare organization. This role is ideal for a nurse with hands-on experience applying MCG criteria, navigating Medicare guidelines, and managing complex inpatient utilization reviews within a health plan, IPA, MSO, or delegated medical group setting.
The ideal candidate is detail-oriented, comfortable working in a fast-paced, metrics-driven environment, and confident communicating clinical findings to Medical Directors, physicians, and hospital teams.
Key Responsibilities
Manage the end-to-end Utilization Management (UM) process, from initial inpatient review through discharge planning.
Conduct daily inpatient and concurrent reviews to assess medical necessity and appropriate levels of care.
Coordinate discharge planning and placements for Durable Medical Equipment (DME), Home Health, Skilled Nursing Facilities (SNF), and Acute Rehabilitation Units (ARU).
Apply MCG (Milliman Care Guidelines) to clinical reviews and develop formal clinical denial letters when appropriate.
Apply Medicare guidelines, including CMS regulations and the 2-midnight rule, to support accurate inpatient status determinations.
Utilize Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) when evaluating pre-service authorizations and appropriate clinical tiers.
Present concise, accurate clinical case summaries during daily multidisciplinary rounds.
Communicate effectively with Medical Directors, treating physicians, and hospital counterparts regarding medical necessity, clinical findings, and discharge plans.
Maintain accurate clinical documentation while meeting established productivity, turnaround-time, and quality standards.
Qualifications
Active, unrestricted California RN or LVN license.
Direct Utilization Management experience in an IPA, MSO, delegated medical group, or health plan setting preferred
Hands-on experience conducting inpatient utilization reviews, including concurrent reviews.
Demonstrated proficiency applying MCG criteria to inpatient acute and/or SNF reviews.
Experience with complex discharge planning, formal denial letters, and Medicare guidelines for SNF and ARU placements.
Strong understanding of CMS regulations, including inpatient versus observation status and the 2-midnight rule.
Knowledge of SNF initial, concurrent, and discharge reviews, as well as QIO, NOMNC, and DENC processes.
Ability to confidently communicate clinical recommendations and present cases to Medical Directors and physicians.
Proficiency with Microsoft Word, Excel, PDF documentation, and standard digital workspace tools.
Strong organizational skills, attention to detail, and the ability to manage a high-volume caseload in a fast-paced environment.
Preferred Qualifications
Five or more years of concurrent inpatient Utilization Management experience.
