Job Description:
• Conduct clinical reviews of inpatient, outpatient, and SNF services to assess medical necessity, appropriateness, and efficiency using evidence-based criteria (e.g., MCG).
• Evaluate and process prior authorization (PA) requests in a timely, compliant manner.
• Collaborate with inpatient providers and case managers to support Transitions of Care (TOC) and discharge planning.
• Communicate clearly with interdisciplinary teams to ensure coordinated and effective care delivery.
• Maintain accurate, comprehensive documentation in systems such as AcuityNxt and other electronic platforms.
• Ensure compliance with Medicare Advantage, state, and federal healthcare regulations.
• Contribute to process improvement initiatives to enhance overall UM effectiveness and efficiency.
Requirements:
• Active, unrestricted RN license (state-specific or compact).
• 3+ years of Utilization Management or related clinical review experience.
• Proven experience with Skilled Nursing Facility (SNF) utilization reviews.
• Strong familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage rules.
• Prior experience in prior authorization (PA) and Transitions of Care (TOC) workflows.
• Excellent clinical communication skills and confidence in engaging with inpatient providers.
• Strong attention to detail, documentation accuracy, and compliance focus.
• Tech-savvy with the ability to quickly adapt to healthcare systems and remote work tools.
Benefits:
• 100% Remote role – enjoy work-life balance while supporting patients across the continuum of care.
• Collaborative, mission-driven healthcare environment.
• Opportunity to expand into Transitions of Care (TOC) initiatives and process optimization.
• Competitive compensation and benefits package.