Utilization Management Nurse (RN)

To support the Utilization Management team, the full-time Utilization Management Nurse (RN) will conduct inpatient, behavioral health, and post-acute authorization reviews remotely, ensuring compliance with CMS and Medicare Advantage regulations. Key responsibilities: Review medical records to evaluate medical necessity and appropriateness of inpatient and post-acute services Assess treatment plans for alignment with medical necessity criteria and recommend alternative levels of care when appropriate Perform concurrent and discharge reviews for inpatient and behavioral health admissions, ensuring regulatory compliance Required qualifications: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, case management, or clinical appeals in a health plan or hospital setting Familiarity with CMS regulations and Medicare Advantage requirements Experience escalating cases that do not meet criteria, including preparing clinical summaries Ability to work one of the posted schedules, including a weekend day for most schedules