Utilization Management RN at Jobgether – United States
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About This Position
This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Utilization Management RN in United States.
This role is focused on ensuring appropriate, evidence-based utilization of healthcare services through rigorous medical necessity review and collaboration with interdisciplinary care teams. You will evaluate patient admissions, monitor continued stay criteria, and ensure alignment with payer guidelines to support appropriate reimbursement and high-quality care delivery. Working in a fast-paced clinical environment, you will act as a key liaison between clinical teams and insurance providers, helping resolve authorization issues and prevent avoidable denials. The role requires strong analytical judgment, deep clinical knowledge, and the ability to interpret complex regulatory and payer requirements. You will also contribute to care coordination efforts by ensuring accurate documentation, timely communication, and effective status determination. This position plays a critical role in optimizing patient flow, safeguarding revenue integrity, and supporting patient-centered care outcomes.
- Conduct admission and concurrent medical necessity reviews to determine appropriate patient status and ensure compliance with payer and regulatory requirements.
- Monitor continued stay reviews and manage pre-bill and concurrent denials to minimize reimbursement loss.
- Collaborate with physicians, care managers, and interdisciplinary teams to ensure appropriate patient status and care coordination.
- Communicate with insurance carriers to obtain and maintain authorizations, ensuring timely updates and resolution of issues.
- Review and interpret payer guidelines, authorization requirements, and medical necessity criteria to support accurate decision-making.
- Track and maintain authorization data within electronic health records and payer systems, ensuring accuracy and compliance.
- Monitor discharge processes and support timely transitions of care while ensuring documentation integrity.
- Active Registered Nurse (RN) license required; Associate or Bachelor of Science in Nursing preferred.
- 3+ years of clinical nursing experience required, with preference for 5+ years in acute care settings.
- Experience in utilization management, case management, or related care coordination roles preferred.
- Strong understanding of medical necessity criteria, payer guidelines, and hospital reimbursement models.
- Familiarity with CPT codes, inpatient admission standards, and regulatory healthcare frameworks.
- Experience working with electronic health records and utilization management tools.
- Excellent analytical, problem-solving, and data interpretation skills.
- Strong communication, negotiation, and organizational abilities with attention to detail and time management.
- Certification such as ACM or CCM is a plus.
- Competitive salary range from $68,132.50 to $119,520.35 annually based on experience and qualifications.
- Comprehensive benefits package including medical, dental, vision, life, and disability insurance from day one.
- Paid time off from the first day of employment.
- Retirement savings plan (403(b)) with employer support.
- 4 weeks of fully paid parental leave.
- Career development opportunities and access to wellness, mental health, and employee support resources.
- Pet benefits and additional lifestyle support programs.