RN Utilization Management Specialist

A company is looking for a Clinical Guide Part A: Utilization Management (Inpatient, Behavioral Health & Post-Acute). Key Responsibilities Conduct utilization reviews to evaluate medical necessity and appropriateness of inpatient and post-acute services Assess treatment plans for alignment with medical necessity criteria and recommend alternative care levels when needed Collaborate with the Medical Director for cases that do not meet criteria and maintain accurate documentation of determinations Required Qualifications Unrestricted RN license with a minimum of 4 years of clinical experience Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting Strong knowledge of CMS regulations and Medicare Advantage requirements Experience preparing cases for Medical Director review Able to work in a fast-paced and evolving environment

Created: 2026-03-05