The Utilization Management Registered Nurse is responsible for conducting utilization management reviews to ensure members receive medically necessary, appropriate, and cost-effective care. The UM RN performs initial and concurrent reviews across inpatient, observation, skilled nursing, acute rehabilitation, LTACH, home health, and other applicable services. The UM RN applies MCG/InterQual criteria, health plan guidelines, CMS regulations, and organizational policies to evaluate medical necessity, level of care, length of stay, and discharge needs. The UM RN collaborates with Medical Directors, providers, facilities, members, families, and interdisciplinary teams to promote quality outcomes and timely transitions of care. The UM RN also supports quality gap closure, care coordination, quality improvement initiatives, NCQA accreditation requirements, and departmental performance goals, while maintaining established productivity, quality, documentation, compliance, and turnaround-time KPIs. ESSENTIAL DUTIES AND RESPONSIBILITIES 33Performs initial and concurrent utilization reviews for inpatient, observation, SNF, acute rehabilitation, LTACH, home health, and other services as assigned. 33Determines medical necessity and appropriateness of care using MCG/InterQual, health plan guidelines, CMS regulations, NCQA standards, and departmental policies. 33Evaluates level of care, length of stay, treatment plans, and discharge needs and identifies opportunities for appropriate transitions to lower levels of care. 33Refers cases not meeting established criteria to the Medical Director and communicates determinations to appropriate parties. 33Collaborates with providers, facilities, Medical Directors, case managers, social workers, and other interdisciplinary team members to facilitate timely and appropriate discharge planning. 33Identifies barriers to discharge and coordinates medically necessary services, authorizations, referrals, and transitions of care. 33Identifies members requiring ongoing case management or additional clinical support and makes appropriate referrals. 33Supports quality initiatives and quality gap closure by identifying opportunities related to preventive care, chronic disease management, screenings, follow-up care, medication adherence, and other applicable quality measures. 33Communicates identified quality gaps to appropriate clinical teams and assists with interventions and closure when applicable. 33Maintains established UM KPIs, including productivity, turnaround time, documentation accuracy, quality, compliance, and service-level expectations. 33Supports the organizations efforts to achieve and maintain NCQA accreditation standards by adhering to applicable policies, workflows, documentation requirements, utilization management standards, and audit requirements. 33Participates in NCQA, health plan, regulatory, and internal audits and ensures assigned UM activities and documentation meet applicable accreditation and regulatory standards. 33Identifies and escalates potential quality-of-care or quality-of-service concerns and participates in quality assurance and improvement activities. 33Reviews utilization data and reports, including admissions, length of stay, avoidable days, readmissions, and other assigned metrics, and identifies opportunities for improvement. 33Participates in UM committees, staff meetings, education, special projects, and process improvement initiatives. 33Maintains accurate, timely, and compliant documentation and protects member confidentiality in accordance with HIPAA and organizational policies. 33Maintains current knowledge of utilization management, Medicare Advantage, managed care, NCQA standards, regulatory requirements, quality initiatives, and clinical guidelines. 33Performs other duties as assigned. KNOWLEDGE, SKILLS AND ABILITIES 33Knowledge of utilization management and medical necessity criteria, including MCG/InterQual. 33Knowledge of Medicare Advantage, HMO, managed care, and post-acute care. 33Knowledge of NCQA accreditation standards and regulatory requirements preferred. 33Knowledge of quality measures and quality gap closure. 33Strong clinical assessment, critical thinking, communication, and documentation skills. 33Ability to manage multiple priorities and meet productivity, quality, compliance, and turnaround-time expectations. 33Proficiency with electronic medical records; Epic/Tapestry experience preferred. 33Ability to work effectively in a multidisciplinary and metrics-driven environment. EDUCATION AND/OR CERTIFICATION/LICENSURE 33Associate/Diploma or Bachelors Degree in Nursing from an accredited nursing program. 33Current, unrestricted Registered Nurse (RN) license. 33CCM or ACM certification preferred. EXPERIENCE 33Minimum of two (2) years of clinical nursing experience, preferably in an acute care setting. 33Two (2) years of experience in Utilization Management, concurrent review, or Case Management in a health plan or hospital setting preferred. 33Experience with Medicare Advantage and HMO populations preferred. 33Experience with NCQA accreditation, quality improvement, HEDIS/Stars, or quality gap closure preferred. The compensation for this role includes a base pay range of $67,953.60- $101K with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.