Registered Nurse - Utilization Review - Acute Care - Part Time Weekends

The Utilization Management (UM) Nurse is responsible for conducting medical necessity reviews, managing patient care transitions, and ensuring appropriate utilization of healthcare services. Key duties include performing daily clinical reviews of admissions, observation cases, and concurrent care using established criteria (e.g., MCG, Indicia), coordinating with physicians and care teams, and facilitating timely authorization of hospital stays and services. They evaluate clinical documentation, monitor post-discharge accounts for discrepancies, and communicate with payers to resolve authorization issues, ensuring compliance with payer and regulatory requirements. Additional responsibilities involve advocating for patients, supporting performance improvement initiatives, and documenting all review activities accurately in the electronic health record system. Qualified candidates should have a minimum of 3 years of clinical experience, an RN license (single-state or multi-state), and strong knowledge of case management, clinical criteria, and documentation practices. Skills required include excellent communication, organization, critical thinking, and computer proficiency. The role emphasizes collaboration, compliance, and continuous professional development.