Job Description:
• Review clinical information to determine the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and levels of care
• Evaluate healthcare services and facilities under applicable health benefit plans to ensure quality and cost-effective patient care
• Collaborate with intake staff, physicians, specialists, case managers, and other care team members
• Facilitate timely and effective care authorizations, transitions, and utilization determinations
• Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria
• Conduct medical necessity reviews for services requiring prior authorization
• Request and evaluate clinical information needed to review requested services
• Discuss cases and determinations with healthcare professionals and physician reviewers
• Identify cases requiring intervention and collaborate with Case Managers
• Maintain accurate documentation and comply with audit standards
• Participate in team meetings, educational sessions, and related activities
• Review medical claims and pre-determinations for medical necessity and appropriateness
• Identify process improvement opportunities and enhance communication among departments
• Consult with Physician Reviewers for complex or challenging cases
Requirements:
• Current, unrestricted RN license (State license required)
• Minimum 3 years of clinical nursing experience
• Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience
• Strong analytical, critical thinking, and problem-solving skills
• Proficiency in Microsoft Office Suite (Excel, Word, Outlook)
• Familiarity with utilization management systems
• Excellent verbal and written communication skills
• Ability to interact effectively with internal and external stakeholders
• Strong organizational and time management skills
• Ability to handle multiple priorities independently
• Comfort with being on camera for virtual meetings (e.g., Microsoft Teams)
• Preferred: Experience with Milliman or Aetna criteria
• Preferred: Background in healthcare administration, medical necessity determination, or benefits management
• Preferred: Experience in data interpretation and medical trend analysis
Benefits:
• Fantastic medical, dental, and vision insurance
• Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible
• Company provided Basic Life and AD&D
• Company paid Short-Term and Long-Term Disability
• Flexible Spending Accounts
• 401(k) Retirement Plan with up to a 6% employer-match
• 100% fully vested after 3 years
• 10+ paid holidays
• Fully Paid half day Summer Fridays
• Generous paid vacation and sick time
• Annual Paid Volunteer Day
• Annual Tuition Reimbursement
• Annual Health and Wellness Reimbursement
• Company events