- Active, unrestricted RN license (or clinical licensure appropriate for UM, e.g., LPN in some markets, LCSW for integrated BH programs).
- 10+ years of clinical experience in utilization management, care management, or clinical review roles within a health plan, hospital, or integrated delivery system.
- Strong understanding of InterQual/MCG criteria, medical necessity reviews, and authorization processes.
- Knowledge of federal and state UM regulations, CMS guidelines, NCQA/URAC standards, and HIPAA.
- Excellent clinical judgment, communication, and documentation skills.
Utilization Review & Clinical Review Oversight
- Conduct and oversee utilization reviews (prospective, concurrent, and retrospective) using evidence based criteria such as InterQual, MCG, CMS, and state guidelines.
- Perform clinical reviews of inpatient, outpatient, specialty, and ancillary services to determine medical necessity, level of care, and appropriateness.
- Support escalation and collaboration with Medical Directors for cases requiring physician review or adverse determinations.
- Ensure UM decision making complies with federal/state regulations, CMS requirements, NCQA/URAC standards, and timeliness expectations.
- Provide coaching to staff on documentation quality, criteria selection, and clinical justification. Service Authorization Management
- Oversee the intake, triage, and review of service authorization requests (e.g., DME, home health, specialty services, behavioral health, advanced imaging).
- Ensure timely processing of authorizations within regulatory and contractual turnaround times (TATs).
- Review complex cases requiring clinical expertise and determine approval, modification, or need for medical director review.
- Monitor volume trends, authorization patterns, and provider issues to identify process improvements. Care Management Integration
- Support transitions of care, coordination between UM and CM, and continuity across inpatient and outpatient settings.
- Participate in interdisciplinary rounds addressing high-risk, complex, or high-cost cases.
- Provide guidance to Care Managers on clinical issues impacting utilization, level of care, or benefit coverage.
- Collaborate with Care Management to identify members requiring engagement in case, disease, or population health programs.
- Bachelor’s or Master’s degree in medicine, Nursing, Healthcare Administration, Public Health, or related field.
- Certification in Case Management or Utilization Management (CCM, ACM-RN, CPUR, CPHM).
- Experience with Medicare Advantage, Medicaid Managed Care, or Commercial health plans.
- Familiarity with UM and CM platforms (e.g., GuidingCare, MHK, HealthEdge, TruCare, CaseTrakker).
- Experience in provider relations, audit support, or process improvement initiatives.
