Utilization Management Nurse - 253234
Now Hiring: Care Manager – Utilization Management & Appeals (RN)
We are seeking an experienced and detail-oriented Care Manager to join our Utilization Management (UM) Appeals team. This role is responsible for managing simple and complex medical cases, supporting high-quality patient outcomes, reducing unnecessary healthcare costs, and ensuring compliance with regulatory standards across inpatient and outpatient services.
Full-Time Contract Opportunity – Through End of Year
Candidates Must Reside in New York — Applicants outside of NY will not be considered
Monday–Friday Schedule (with occasional rotational oversight for expedited appeals)
Key Responsibilities:
• Perform utilization management activities including inpatient admission certification, concurrent review, discharge planning, outpatient and ancillary service review
• Evaluate medical necessity, level of care (LOC), and length of stay (LOS) using InterQual, CMS/Medicare Guidelines, and internal medical policies
• Review and process clinical appeals in partnership with Physician Advisors while ensuring compliance with regulatory turnaround times
• Coordinate with External Review Agencies (ERA) and Clinical Peer Reviewers to facilitate timely case resolution
• Maintain accurate documentation within UM/Appeals systems to support compliance and audit readiness
• Collaborate with PCPs, providers, and members to coordinate care and communicate appeal determinations and treatment alternatives
• Identify utilization trends and member needs through data analysis, pharmacy claims review, and health assessments
• Escalate complex cases appropriately to Physician Advisors or Medical Directors
Qualifications:
✔ Active, unrestricted RN license
✔ 3+ years of experience in Utilization Management, Clinical Appeals, Discharge Planning, or related care management functions
✔ Appeals or UM/UR experience within managed care or hospital settings required
✔ Strong knowledge of InterQual or MCG criteria and CMS/Medicaid/Medicare guidelines
✔ Experience with UM platforms such as HealthEdge, Jiva, or Salesforce Health Cloud preferred
✔ Strong clinical judgment, documentation, and communication skills
If you are passionate about improving patient outcomes, navigating complex clinical cases, and making an impact in healthcare operations, we’d love to hear from you.
#NowHiring #CareManager #UtilizationManagement #ClinicalAppeals #RNJobs #CaseManagement #ManagedCare #HealthcareJobs #NursingJobs #NewYorkJobs #ContractJobs #HealthcareCareers
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We are seeking an experienced and detail-oriented Care Manager to join our Utilization Management (UM) Appeals team. This role is responsible for managing simple and complex medical cases, supporting high-quality patient outcomes, reducing unnecessary healthcare costs, and ensuring compliance with regulatory standards across inpatient and outpatient services.
Full-Time Contract Opportunity – Through End of Year
Candidates Must Reside in New York — Applicants outside of NY will not be considered
Monday–Friday Schedule (with occasional rotational oversight for expedited appeals)
Key Responsibilities:
• Perform utilization management activities including inpatient admission certification, concurrent review, discharge planning, outpatient and ancillary service review
• Evaluate medical necessity, level of care (LOC), and length of stay (LOS) using InterQual, CMS/Medicare Guidelines, and internal medical policies
• Review and process clinical appeals in partnership with Physician Advisors while ensuring compliance with regulatory turnaround times
• Coordinate with External Review Agencies (ERA) and Clinical Peer Reviewers to facilitate timely case resolution
• Maintain accurate documentation within UM/Appeals systems to support compliance and audit readiness
• Collaborate with PCPs, providers, and members to coordinate care and communicate appeal determinations and treatment alternatives
• Identify utilization trends and member needs through data analysis, pharmacy claims review, and health assessments
• Escalate complex cases appropriately to Physician Advisors or Medical Directors
Qualifications:
✔ Active, unrestricted RN license
✔ 3+ years of experience in Utilization Management, Clinical Appeals, Discharge Planning, or related care management functions
✔ Appeals or UM/UR experience within managed care or hospital settings required
✔ Strong knowledge of InterQual or MCG criteria and CMS/Medicaid/Medicare guidelines
✔ Experience with UM platforms such as HealthEdge, Jiva, or Salesforce Health Cloud preferred
✔ Strong clinical judgment, documentation, and communication skills
If you are passionate about improving patient outcomes, navigating complex clinical cases, and making an impact in healthcare operations, we’d love to hear from you.
#NowHiring #CareManager #UtilizationManagement #ClinicalAppeals #RNJobs #CaseManagement #ManagedCare #HealthcareJobs #NursingJobs #NewYorkJobs #ContractJobs #HealthcareCareers
Apply tot his job
Apply To this Job