Utilization Management Nurse

The role works with the Utilization Management team, primarily responsible for inpatient medical necessity/utilization reviews and other UM activities aimed at ensuring Client's Healthcare members receive appropriate care in the right setting at the right time. Key responsibilities include daily review and evaluation of members requiring hospitalization and/or procedures, providing prior authorizations and/or concurrent review, and ensuring services are cost-effective and compliant with state and federal regulations.

Conducts concurrent reviews and prior authorizations according to Client policy for members. Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments or procedures. Collaborates with other departments to enhance continuity of care for members, including Behavioral Health and Long-Term Care. Maintains productivity and quality standards within the department. Participates in staff meetings and assists with mentoring new team members. Completes assigned work plan objectives and projects on time. Maintains professional relationships with providers and internal/external customers. Regularly consults with and refers cases to Client medical directors as needed. Ensures compliance with workplace safety standards and company policies.