Utilization Review Nurse (Medicare)

Job Overview: The Medicare Utilization Management (UM) Nurse is responsible for reviewing and processing authorization requests to determine medical necessity, ensure appropriate utilization of healthcare services, and maintain compliance with applicable Medicare regulations, clinical criteria, and organizational policies.

While medical necessity reviews are outsourced, position also includes oversight of the submissions and outcomes of the clinical reviews being done by the external vendor.

This role requires strong clinical judgment, analytical skills, exceptional attention to detail, and the ability to identify discrepancies, inconsistencies, errors, and process deficiencies that may impact member care, regulatory compliance, and data integrity.

The UM Nurse collaborates with multidisciplinary teams to promote timely access to medically necessary services, maintains accurate Medicare Part C data and Odag reports, prepares appeal summaries for Level II submissions, and participates in quality improvement initiatives.

Essential Responsibilities: May assess and process authorization requests to determine medical necessity and appropriateness of care in accordance with applicable Medicare coverage criteria, regulatory requirements, clinical guidelines, and organizational policies.

Perform utilization review activities, including preauthorization, concurrent, discharge, and post-service reviews, as applicable.

Work collaboratively with multidisciplinary teams to identify and manage members who may require additional care coordination, support, or services in the home to improve quality of life and ensure individualized care needs are met.

Deliver timely and accurate notifications regarding clinical determinations and implement appropriate interventions to minimize delays in care and prevent inappropriate denials.

Communicate with physicians and other healthcare professionals to obtain additional clinical information when necessary to support medical necessity determinations.

Prepare and/or audit accurate and compliant action notices for adverse determinations, including denials and reductions in services, in accordance with applicable regulatory requirements and organizational policies.

Ensure utilization management decisions are clinically appropriate, financially responsible, ethically sound, and compliant with governing regulations while prioritizing member welfare and well-being.

Ensure notices are written in 4th to 6th grade reading level.

Validate the accuracy, completeness, and consistency of Medicare Part C data and Odag reports, as well as other applicable regulatory and operational reports, identifying and resolving discrepancies, missing information, and reporting errors before submission or finalization.

Review clinical records, authorization data, determinations, notices, and supporting documentation to ensure all information is accurate, consistent, complete, and reflective of the services requested and the decisions rendered.

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