Utilization Management Nurse
Core
Conducts concurrent and retrospective utilization reviews to ensure medical necessity and compliance with regulatory guidelines for patient care plans.
Role type
Utilization Management Nurse
Builds
Care delivery timelines and compliance with payer/regulatory standards
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Utilization review criteria application, critical thinking for clinical scenario analysis, knowledge of healthcare regulations and reimbursement, age-specific patient care assessment, data collection and denial management
Preferred skills
Experience in quality management, conflict resolution, professional relationship building with physicians
Technologies
Microsoft Office (Excel, Outlook, PowerPoint, Word)
Responsibilities
Document utilization review activity per department standards, communicate with healthcare teams to expedite care delivery, collaborate with physicians and treatment teams on plan of care, provide clinical updates to payers and external review organizations, serve as an educator on admission status and acute care criteria
Seniority
Mid-level, hands-on IC