Job Description

Full Time Days

7am-4:30pm

40 Hours/Week

Summary

Utilization management and pediatric nursing experience preferred

The Utilization Management Nurse is responsible for conducting medical necessity review to assure appropriate use of hospital resources and serving as a resource to the hospital staff on utilization management practices.

Responsibilities

• Conduct Utilization Review & Determine Appropriate Level of Care

Applies evidence‑based medical necessity criteria, validates admission status, and ensures all inpatient, observation, and outpatient-in-a-bed cases meet criteria. Collaborates proactively with physician advisors and attending providers for accurate level‑of‑care decisions and authorization of hospital days.

• Manage Denials, Compliance, and Quality Improvement Activities

Participates in denial management and peer review processes, identifies compliance or ethical issues, and contributes to quality and safety initiatives aimed at improving departmental and hospital workflows.

• Support Care Progression Through Interdisciplinary Collaboration

Actively engages in daily huddles, multidisciplinary rounds, and patient care discussions to understand service intensity, discharge barriers, and progression of care, while serving as a resource to the care team on utilization, documentation, and admission requirements.

• Maintain Accurate and Timely Documentation

Clearly documents all reviews, interactions, and decisions in Midas, Epic, and other required systems.

• Performs additional duties as assigned.

Other Information

Technical Expertise

• Experience in inpatient clinical is required.
• Experience in pediatrics is preferred.
• Experience working with all levels within an organization is required.
• Experience in healthcare is required.
• Proficiency in MS Office [Outlook, Excel, Word] or similar software is required.

Education And Experience

• Education: Bachelor's in nursing [BSN] is required. For employees hired after July 1, 2013, BSN is required or must be obtained within 5 years from date of hire.
• Certification: Registered Nurse licensure is required.
• Years of relevant experience: 3 years is required.
• Years of experience supervising: None.

Full Time

FTE: 1.000000

Status: Remote

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