Utilization Review Nurse

We are seeking a highly skilled and motivated Registered Nurse (RN) to join our team. The ideal candidate will have a strong background in clinical practice and possess expertise in utilization review, case management, and patient care. This role involves performing prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care. Additionally, the candidate may establish care plans and coordinate care through the healthcare continuum, including member outreach assessments.

Key Responsibilities:

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services.
• Ensure medical necessity, appropriate length of stay, intensity of service, and level of care.
• Handle appeal requests initiated by providers, facilities, and members.
• Establish care plans and coordinate care through the healthcare continuum, including member outreach assessments.
• Collaborate with cross-functional teams to improve patient care and healthcare delivery processes.
• Analyze data and provide insights to improve healthcare outcomes.
• Ensure compliance with industry standards and regulations.

Qualifications:

• Bachelor's degree in nursing, allied health, business, or related field preferred.
• Two (2) to four (4) years of clinical experience, which may include acute patient care, discharge planning, case management, and utilization review1.
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes.
• One (1) year of health insurance plan experience or managed care environment preferred1.
• Registered Nurse with current unrestricted Michigan Registered Nurse license required1.
• Certification in Case Management may be preferred based upon designated department assignment.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Ability to work independently and as part of a team.

Preferred Skills:

• Experience with Milliman and InterQual.
• Knowledge of industry-specific knowledge or certifications.
• Strong organizational and time management skills.