This role focuses on concurrent utilization review for inpatient Medicare members, applying evidence-based criteria to determine medical necessity and appropriate levels of care. The nurse reviews authorization requests, discharge plans, and post-acute needs, while also considering coding accuracy, policy compliance, and quality of care concerns.
Work includes prospective, concurrent, and retrospective reviews across Medicare and other lines of business, with communication of determinations to providers and members. The position also involves preparing cases for Medical Director review, documenting decisions, and participating in clinical rounds, huddles, and team meetings in a hybrid virtual setting.
Key Responsibilities
- Conduct prospective, concurrent, and retrospective utilization reviews using evidence-based and nationally recognized criteria.
- Review authorization requests for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Assess discharge planning needs, including level of care, durable medical equipment, and post-acute services.
- Prepare and present cases to the Medical Director for oversight and necessity determination.
- Communicate determinations to providers and/or members in compliance with regulatory and accreditation requirements.
- Develop member-centered documentation and correspondence that reflect utilization decisions.
- Identify potential quality of care issues, service delays, or treatment delays and escalate as appropriate.
- Refer members to Case Management when acute inpatient needs affect discharge.
- Participate in staff meetings, clinical rounds, and weekly huddles while maintaining quality and productivity metrics.
Required
- Active, unrestricted California RN license.
- Associate’s degree in nursing.
- At least 5 years of relevant experience.
- Strong communication and computer navigation skills.
- Ability to work independently with strong critical thinking and work ethic.
Preferred
- Bachelor of Science in Nursing.
- Strong teamwork and collaboration skills.
Benefits & Perks
- Hybrid virtual work arrangement with virtual work full time and office time based on business need.
- Opportunity to work across Medicare and other major lines of business.
- Supportive team workflows including clinical rounds, huddles, and peer support for new employees.
- Telework-friendly setup with HIPAA-compliant workspace expectations.