Registered Nurse Utilization Management Overview • The Registered Nurse Utilization Management role focuses on ensuring effective healthcare service delivery through comprehensive utilization management practices. • Collaborate with a multidisciplinary team to manage medical necessity reviews and authorization determinations. • Utilize Milliman Care Guidelines to evaluate service appropriateness and ensure compliance with policies. • Perform concurrent and retrospective reviews to maintain high-quality healthcare standards. • Engage in productivity metrics and turnaround time adherence to optimize operational efficiency. • Collaborate with consultants on denials and appeals processes to ensure patient satisfaction. • Opportunity to work with advanced systems like DMS and QNXT for effective case management. • Contribute to a dynamic healthcare environment with potential for temp-to-perm transition. Registered Nurse Utilization Management Key Responsibilities & Duties • Conduct medical necessity reviews including concurrent, prospective, and retrospective evaluations. • Apply clinical guidelines and benefit plan designs to optimize service delivery. • Maintain accurate records and documentation in designated medical management systems. • Collaborate with medical consultants to discuss and review cases. • Ensure compliance with state regulations and organizational policies. • Identify and resolve service-related issues to enhance member outcomes. • Participate in quality improvement initiatives and operational studies. • Authorize vendor services using clinically proven criteria for consistent care decisions. Registered Nurse Utilization Management Job Requirements • Bachelor’s degree in Nursing and valid New York State Registered Nurse (RN) license. • Minimum three years of medical/surgical experience and two years in utilization management. • Proficiency in Milliman Care Guidelines and industry-standard utilization management practices. • Strong communication, problem-solving, and independent decision-making skills. • Experience with DMS and QNXT systems is highly preferred. • Intermediate proficiency in Microsoft Office and ability to multitask effectively. • Certification in Case Management is a plus. • Ability to thrive in a fast-paced healthcare environment and manage competing priorities.