Utilization Management Nurse
Hybrid
Core
Evaluate and pre-certify provider requests for hospital stays, surgeries, and tests via telephone to ensure medical necessity and adherence to evidence-based guidelines.
Role type
Utilization Management Nurse (RN)
Builds
Care authorization decisions and referrals to case/condition management services
Domain
Health insurance / Utilization management
Required skills
RN license, clinical experience (ER, ICU, mental health, orthopedics, pain management), multitasking, evidence-based guideline application
Preferred skills
Bilingual, fast-paced environment adaptability
Responsibilities
Handle multiple provider phone calls simultaneously, review care requests against guidelines, coordinate referrals to case management services
Seniority
Individual Contributor