Utilization Management- RN

About the role

The RN Utilization Management nurse is a member of the UM team responsible for conducting medical necessity reviews for pre-service/prior authorization, post-service/retrospective reviews, and other assigned utilization reviews based on product requirements, service type, and organizational workflow. This role reviews clinical information, applies appropriate medical necessity criteria, and ensures coverage determinations are completed accurately and within required regulatory and organizational timeframes. The UM RN works collaboratively with providers, medical directors, internal departments, and other stakeholders to support appropriate, timely, and member-centered care.

Responsibilities

• Accurately and consistently perform pre-service, concurrent, and post-service clinical reviews by applying established medical necessity criteria, guidelines, benefit requirements, and organizational policies.
• Utilize clinical judgment to evaluate treatment appropriateness and level of care, document review determinations clearly and in compliance with regulatory and professional standards and prepare and escalate cases to the Medical Director when required.
• Collaborate with members, clinic/hospital staff and other providers effectively to identify and obtain additional clinical information as needed to support complete, timely, and accurate review decisions within turnaround time requirements for all products.
• Maintain assigned workload and complete responsibilities within timelines established by regulatory requirements and departmental policies and procedures.
• Incorporate quality by identifying opportunities for refinement or improvement of the UM program, participating in continuous improvement process efforts, and successfully completing annual regulatory inter-rater reliability testing.
• Display understanding of the organization’s products, benefits, provider network, and contracts, ensuring the member receives services through contracted providers as appropriate and available while minimizing out-of-network migration whenever possible.
• Collaborate with claims, the provider contact center, provider relations, and contracting on ad hoc provider education activities, and participate in committees or work groups as needed.

Requirements

• Current, valid, and unrestricted Minnesota RN License.
• Requires a minimum of 3 years’ clinical experience in a health care setting.
• Experience with Microsoft Office Suite.
• Strong written and verbal communication skills.
• Ability to multitask and balance priorities.

Qualifications

• Preferred: Previous utilization management experience, experience in interpreting managed care benefit plans and strong knowledge of government programs (Medicare and Medicaid).
• Previous experience interpreting and applying established clinical review criteria and guidelines such as State and Federal guidelines, InterQual, or internal health plan policies.
• Experience with telephonic communication and provider follow-up.

Skills

• Ability to interpret clinical records, apply critical thinking, and make sound clinical recommendations;
• Strong clinical decision-making skills;
• Clear written and verbal communication skills, especially with providers, members, and internal teams;
• Strong attention to detail and accuracy in electronic clinical documentation;
• Experience in electronic medical records;
• Strong MS Word, Excel, and Outlook skills;
• Ability to work independently and as part of a team;
• Time management skills with the ability to prioritize and adjust to fluctuating workflows and changing assignments.

Benefits

South Country Health Alliance offers comprehensive benefits including medical, dental, vision, life insurance, short- and long-term disability, pension (PERA), and more. Work-life flexibility is also provided, along with predictable pay growth through a structured step-based salary system for transparency and stability. The pay for this position ranges from $34.39 - $47.94 per hour.

Pay

The pay for this position ranges from $34.39 - $47.94 per hour.

Schedule

This position involves a rotating on-call schedule, as required, to meet departmental and regulatory time frames during weekends and holidays.