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Utilization Management - RN

Impresiv Health

Role overview

Qualifications

  • Active Registered Nurse (RN) license
  • Graduate of an accredited School of Nursing
  • Minimum 4 years of clinical nursing experience
  • Minimum 2 years of managed care or HMO experience

Responsibilities

  • Perform concurrent, prior authorization, and retrospective utilization reviews
  • Evaluate medical necessity using InterQual, MCG, CMS, LCD/NCD, and health plan guidelines
  • Coordinate discharge planning and transitions of care with providers and healthcare facilities
  • Collaborate with physicians, hospital staff, specialists, and internal care management teams

Key facts

Hard skills

Nursing Utilization Management Medical Necessity Discharge Planning Transitional Care Clinical Documentation InterQual Criteria Emergency Departments

Other skills

  • Critical Thinking
  • Microsoft Office
  • Communication
  • Organizational Skills

About the company

Impresiv Health logo

Impresiv Health

Business Consulting & Services

Company details

Company typeSME
IndustryBusiness Consulting & Services

Links

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Job description

Description:
Our client is seeking an experienced Concurrent Review Registered Nurse (RN) to join its Utilization Management team. In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care while collaborating with physicians, hospitals, and interdisciplinary teams to ensure members receive appropriate, cost-effective, and evidence-based care. This position is ideal for an RN with strong acute care experience and a background in managed care, utilization management, or case management.

What You Will Do:
  • Perform concurrent, prior authorization, and retrospective utilization reviews.
  • Evaluate medical necessity using InterQual, MCG, CMS, LCD/NCD, and health plan guidelines.
  • Coordinate discharge planning and transitions of care with providers and healthcare facilities.
  • Collaborate with physicians, hospital staff, specialists, and internal care management teams.
  • Request and review additional clinical documentation when necessary.
  • Escalate complex medical necessity cases to the Medical Director.
  • Educate providers on utilization management policies and review criteria.
  • Document all reviews and clinical decisions accurately within medical management systems.
  • Identify care gaps and support quality improvement initiatives.
  • Serve as a clinical resource for internal teams.
You Will Be Successful If:
  • You have strong clinical judgment and are confident making medical necessity determinations.
  • You can effectively communicate with physicians, hospitals, and multidisciplinary teams.
  • You are highly organized and able to manage multiple cases simultaneously.
  • You thrive in a fast-paced managed care environment.
  • You are comfortable navigating challenging conversations regarding levels of care.
  • You are detail-oriented and committed to delivering high-quality patient outcomes.
What You Will Bring:
  • Active Registered Nurse (RN) license with the ability to obtain licensure in multiple states.
  • Graduate of an accredited School of Nursing.
  • Minimum 4 years of clinical nursing experience.
  • Minimum 2 years of managed care or HMO experience.
  • Experience performing medical necessity reviews using evidence-based clinical guidelines.
  • Strong knowledge of: Concurrent Review, Utilization Management, Discharge Planning, Transitions of Care
  • Experience applying: InterQual, MCG, CMS Guidelines
  • Experience working with medical management software and Microsoft Office.
  • Excellent communication, critical thinking, and organizational skills.
Preferred Experience
  • Bachelor of Science in Nursing (BSN).
  • Emergency Department (ER) experience.
  • Intensive Care Unit (ICU) experience.
  • Case Management experience.
  • Utilization Management experience within a health plan or managed care organization.
  • Experience working directly with hospitals, physicians, and provider networks.
About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical and operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions that solve their most complex business challenges.

Our approach has always been simple. We think and act like the customers who need us and deliver tangible results that larger organizations often cannot provide. We focus on creating immediate value through responsive service, experienced consultants, and a commitment to our clients' success.

That's Impresiv!

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Marcus Rivera

Chief Revenue Officer

m.rivera@company.com
linkedin.com/in/marcusrivera
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