Utilization Management RN

Active, unrestricted Registered Nurse (RN) license. Minimum of 3 years of experience in Utilization Management or related clinical review settings. Experience working with Skilled Nursing utilization reviews. Strong familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage guidelines. Prior Authorization (PA) processes experience. Transitions of Care (TOC) background. Comfort communicating with inpatient providers and clinical teams. Strong proficiency in documentation and navigating healthcare systems/platforms.

Conduct clinical reviews of inpatient, outpatient, and Skilled Nursing Facility (SNF) services to assess medical necessity. Evaluate and process prior authorization (PA) requests. Collaborate with inpatient providers to support clinical decision-making and coordinate transitions of care. Communicate with case managers, providers, and interdisciplinary teams for care coordination. Participate in Transitions of Care (TOC) initiatives. Maintain clear, comprehensive, and compliant documentation within internal systems (e.g., AcuityNxt). Ensure adherence to organizational policies, Medicare Advantage rules, and state/federal regulations.