Utilization Management RN

The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and assessing the medical necessity, appropriateness, and efficiency of healthcare services requested by providers and members. This role supports the health plan’s utilization management functions in alignment with clinical guidelines, plan benefits, regulatory requirements, and accreditation standards.

The UM Nurse ensures the delivery of cost-effective, high-quality care for members through a variety of activities including utilization review of inpatient, outpatient, and ancillary services using standardized clinical criteria such as MCG and Inter Qual.

Candidates must hold an Associate Degree in Nursing and maintain an active, unrestricted Registered Nurse (RN) license in the applicable state or possess a compact license.

A minimum of three years of prior experience in utilization management within a health insurance company is required.

Strong familiarity with MCG, Inter Qual, or CMS criteria is essential, as is a working knowledge of UM-related regulatory and accreditation standards such as CMS, NCQA, and URAC.

The role requires advanced clinical judgment, critical thinking, and communication skills, along with proficiency in electronic medical records and utilization management systems.

Preferred qualifications include a Bachelor’s Degree in Nursing and professional certification in Case Management or Utilization Review, such as CCM, CPUR, or CPUM.

Experience using UM platforms such as Tru Care, Guiding Care, Jiva, or similar systems is desirable, along with previous involvement in appeals, grievances, concurrent review, or behavioral health utilization management.

A multistate compact RN license is also preferred.