Utilization Management Nurse RN

Job Summary

A company is looking for a Utilization Management Nurse.

Key Responsibilities

• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews
• Reviews, documents, and communicates all utilization review activities and outcomes

Required Qualifications

• Registered Nurse with a current license to practice in the state of employment
• Current compact RN Licensure to practice in applicable states
• 2+ years of experience in managed care, Utilization Review, or Case Management, or 5+ years nursing experience
• Relevant experience in UM process activities such as prior authorization or medical claims review
• Knowledge of medical terminology, ICD-9/ICD-10, and CPT