Utilization Management Nurse - Full-Time Day

Role: On-site Hospital Utilization Management (UM) Nurse responsible for optimizing hospital resources through real-time clinical and administrative collaboration.

Responsibilities

• Perform admission and concurrent medical record reviews to determine appropriate patient classification (e.g., inpatient, outpatient, observation).
• Meet face-to-face with physicians and interdisciplinary teams for case discussions, ensuring documentation supports medical necessity.
• Participate in bedside rounds and departmental huddles to provide immediate input on care progression and medical necessity.
• Assess patient care plans using criteria like InterQual or MCG, and monitor compliance with payer and regulatory standards.
• Deliver legally required notices, identify avoidable hospital days, and escalate issues to minimize financial loss.
• Collaborate with physicians and physician advisors for complex medical necessity determinations and review managed care denials.
• Complete accurate documentation, ensure timely record updates, and support continuous performance improvement initiatives.

Qualifications & Skills

• Associates or Bachelor’s Nursing degree preferred.
• Active RN license (single or multi-state), with BLS certification required upon hire.
• Minimum of 3 years of clinical experience with strong clinical knowledge.
• Excellent communication, collaboration, and documentation skills.

Additional: Serves as a mentor/preceptor, adheres to organizational policies, and performs other duties as assigned.