Description
The Utilization Management Registered Nurse reviews inpatient and outpatient patient cases for medical necessity, appropriate level of care, payer compliance, and efficient use of healthcare resources. The role collaborates with physicians, case managers, and interdisciplinary teams; obtains insurance authorizations; monitors length of stay; documents findings; supports denial prevention and appeals; and contributes to quality improvement and care coordination. An active RN license, 2–3 years of acute care hospital nursing experience, knowledge of InterQual or MCG criteria, and EMR experience are required, while a BSN and prior utilization management, case management, or care coordination experience are preferred.
