Utilization Management - RN
On-siteSunnyvale, California, United States
Job Summary
Perform concurrent, prior authorization, and retrospective utilization reviews while evaluating medical necessity using InterQual, MCG, CMS, and health plan guidelines. Coordinate discharge planning and transitions of care with providers and facilities, request additional clinical documentation, and escalate complex cases to the Medical Director. Educate providers on utilization policies, document decisions in medical management systems, and identify care gaps to support quality improvement initiatives. This 6-month contract in Long Beach, CA, requires an RN with Medicare Advantage experience and strong acute care background.
Required Qualifications
- Must have experience with Medicare Advantage
- Must have experience with Concurrent Review
- Must have experience with Inpatient
- Must have experience with Utilization Management
- Must have experience with Discharge Planning
- Must have experience with Transitions of Care
- Active Registered Nurse (RN) license with the ability to obtain licensure in multiple states
- Graduate of an accredited School of Nursing
- Minimum 4 years of clinical nursing experience
- Minimum 2 years of managed care or HMO experience
- Experience performing medical necessity reviews using evidence-based clinical guidelines
- Strong knowledge of: Concurrent Review, Utilization Management, Discharge Planning, Transitions of Care
- Experience applying: InterQual, MCG, CMS Guidelines
- Experience working with medical management software and Microsoft Office
- Excellent communication, critical thinking, and organizational skills
Desired Qualifications
- Bachelor of Science in Nursing (BSN)
- Emergency Department (ER) experience
- Intensive Care Unit (ICU) experience
- Case Management experience
- Utilization Management experience within a health plan or managed care organization
- Experience working directly with hospitals, physicians, and provider networks
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