Utilization Management RN
Company:HJ Staffing
Location:Roseburg, OR
Languages:English
Seniority level:Middle, 3+ years
Experience:3+ years
Requirements:
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. Experience with Prior Authorization (PA) processes. Experience with Transitions of Care (TOC) background. Comfort communicating with inpatient providers and clinical teams. Strong proficiency in documentation and navigating healthcare systems/platforms.
Responsibilities:
Conduct clinical reviews of inpatient, outpatient, and Skilled Nursing Facility (SNF) services. Evaluate and process prior authorization (PA) requests. Collaborate with inpatient providers to support clinical decision-making and transitions of care. Communicate with case managers, providers, and interdisciplinary teams. Participate in Transitions of Care (TOC) initiatives. Maintain clear, comprehensive, and compliant documentation within internal systems. Ensure adherence to organizational policies, Medicare Advantage rules, and state/federal regulations.
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