Current, active, unrestricted RN license in applicable state(s) or U.S. territory.
Associate's Degree in Nursing required; Bachelor's degree preferred.
Minimum of 5 years of: Acute care clinical experience, or
Case management, utilization management, or managed care experience,
Or any combination of education and experience providing equivalent background.
Prior managed care or health plan/MSO experience strongly preferred.
Participation in the American Association of Managed Care Nurses (AAMCN) preferred.
Required Knowledge & Skills
Strong knowledge of: Medical management processes
Medical necessity review criteria (MCG, InterQual)
Member contracts and benefit interpretation
Managed care products
Understanding of Medicare/Medicaid regulations.
Strong clinical judgment within RN scope of practice.
Excellent oral, written, and interpersonal communication skills.
Strong analytical, problem-solving, and facilitation skills.
Proficiency with EMRs, review platforms, and Microsoft Office applications.
Ability to manage multiple priorities in a fast-paced or remote environment.
Benefits
Health insuranceRemote work options
Additional Information
Job Description Summary
The UM Nurse Lead is responsible for conducting and overseeing clinical utilization management activities to ensure medically appropriate, high-quality, and cost-effective care for members. This role collaborates with healthcare providers, members, and operational leadership to promote quality outcomes, optimize member benefits, and support effective resource utilization particularly for complex medical cases.
The UM Nurse Lead serves as a subject matter expert within the department, supports regulatory and accreditation readiness, and may lead intradepartmental initiatives and team activities.
How will you make an impact & Requirements
Clinical Utilization Management
Conduct prospective, concurrent, and retrospective reviews for: Inpatient admissions
Continued stay reviews
Outpatient services
Surgical and diagnostic procedures
Out-of-network services
Appropriateness of treatment setting
Apply evidence-based guidelines (e.g., MCG, InterQual), CMS regulations, medical policies, and industry standards to determine medical necessity.
Accurately interpret and apply member eligibility, benefits, contracts, and managed care products.
Ensure compliance with regulatory and accreditation standards (e.g., NCQA, URAC, CMS).
Collaboration & Care Coordination
Collaborate with providers and members to promote quality outcomes and cost-effective care.
Work closely with Regional Medical Directors for: Interpretation of complex cases
Medical necessity clarification
Non-certification determinations (does not independently issue denials when physician review is required).
Facilitate care transitions across the healthcare continuum.
Refer treatment plans to clinical reviewers and/or Medical Directors as required.
Appeals & Compliance
Participate in the review and coordination of appeals for services denied.
Ensure documentation is complete, accurate, and compliant with internal policies and regulatory standards.
Facilitate accreditation readiness by understanding and correctly applying accrediting and regulatory requirements.
Leadership & Oversight
Serve as a clinical resource to team members.
Provide guidance on medical policy interpretation and UM processes.
Participate in or lead intradepartmental teams, projects, and quality improvement initiatives.
Identify trends in utilization patterns and contribute to performance improvement strategies.
Support staff training and onboarding activities as needed.
Verawholehealth · Remote