Utilization Management Registered Nurse (UM RN)

At Duly Health and Care , you are supported to do your best work and make a meaningful impact every day. You will be part of a collaborative, physician-led team that works as one and puts patients at the center of everything we do.

With a connected network of providers, care teams, and services across primary and specialty care, surgery centers, imaging, lab, and therapy, you are part of a system designed to deliver high-quality, coordinated care. Together, we create an environment where you can grow, contribute, and help improve the experience and outcomes for every patient we serve.

Benefits:

• Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
• Access to a mental health benefit at no cost.
• Employer provided life and disability insurance.
• $5,250 Tuition Reimbursement per year.
• Immediate 401(k) match.
• 40 hours paid volunteer time off.
• A culture committed to community engagement and social impact.
• Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.

The Utilization Management Registered Nurse   is responsible for   conducting   utilization   management reviews to ensure members receive medically necessary,   appropriate , and cost-effective care. The UM RN performs initial and concurrent reviews across inpatient, observation, skilled nursing, acute rehabilitation, LTACH, home health, and other applicable services.

The UM RN   applies   MCG/InterQual criteria, health plan guidelines, CMS regulations, and organizational policies to evaluate medical necessity, level of care, length of stay, and discharge needs. The UM RN collaborates with Medical Directors, providers, facilities, members, families, and interdisciplinary teams to promote quality outcomes and   timely   transitions of care.

The UM RN also supports quality gap closure, care coordination, quality improvement initiatives, NCQA accreditation requirements, and departmental performance goals, while   maintaining   established productivity, quality, documentation, compliance, and turnaround-time KPIs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

- Performs initial and concurrent   utilization   reviews for inpatient, observation, SNF, acute rehabilitation, LTACH, home health, and other services as assigned.

- Determines   medical necessity and appropriateness of care using MCG/InterQual, health plan guidelines, CMS regulations, NCQA standards, and departmental policies.

- Evaluates level of care, length of stay, treatment plans, and discharge needs and   identifies   opportunities for   appropriate transitions   to lower levels of care.

- Refers   cases not meeting established criteria to the Medical Director and communicates determinations to   appropriate parties.

- Collaborates with providers, facilities, Medical Directors, case managers, social workers, and other interdisciplinary team members to   facilitate   timely   and   appropriate discharge   planning.

- Identifies   barriers to discharge and   coordinates   medically necessary services, authorizations, referrals, and transitions of care.

- Identifies   members requiring ongoing case management or   additional   clinical support and   makes   appropriate referrals.

- Supports   quality initiatives and quality gap closure   by   identifying   opportunities related to preventive care, chronic disease management, screenings, follow-up care, medication adherence, and other applicable quality measures.

- Communicates identified quality gaps to appropriate clinical teams and   assists   with interventions and closure when applicable.

- Maintains established   UM KPIs , including productivity, turnaround time, documentation accuracy, quality, compliance, and service-level expectations.

- Supports the organization's efforts to   achieve and maintain NCQA accreditation standards   by adhering to applicable policies, workflows, documentation requirements,   utilization   management standards, and audit requirements.

- Participates in NCQA, health plan, regulatory, and internal audits and ensures assigned UM activities and documentation meet applicable accreditation and regulatory standards.

- Identifies   and escalates potential quality-of-care or quality-of-service concerns and   participates   in quality assurance and improvement activities.

- Reviews   utilization   data and reports, including admissions, length of stay, avoidable days, readmissions, and other assigned metrics, and   identifies   opportunities for improvement.

- Participates   in UM committees, staff meetings, education, special projects, and process improvement initiatives.

- Maintains   accurate ,   timely , and compliant documentation and protects member confidentiality   in accordance with   HIPAA and organizational policies.

- Maintains current knowledge of   utilization   management, Medicare Advantage, managed care, NCQA standards, regulatory requirements, quality initiatives, and clinical guidelines.

- Performs other duties as assigned.

KNOWLEDGE,   SKILLS   AND ABILITIES

- Knowledge of   utilization   management and medical necessity criteria, including MCG/InterQual.

- Knowledge of Medicare Advantage, HMO, managed care, and post-acute care.

- Knowledge of NCQA accreditation standards and regulatory requirements preferred.

- Knowledge of quality measures and quality gap closure.

- Strong clinical assessment, critical thinking, communication, and documentation skills.

- Ability to manage multiple priorities and meet productivity, quality, compliance, and turnaround-time expectations.

- Proficiency   with electronic medical records; Epic/Tapestry experience preferred.

- Ability to work effectively in a multidisciplinary and   metrics-driven environment.

EDUCATION AND/OR CERTIFICATION/LICENSURE

- Associate/Diploma or   Bachelor's Degree in Nursing   from an accredited nursing program.

- Current, unrestricted Registered Nurse (RN) license.

- CCM or ACM certification preferred.

EXPERIENCE

- Minimum of two (2) years of clinical nursing experience, preferably in an acute care setting.

- Two (2) years of experience in Utilization Management, concurrent review, or Case Management in a health plan or hospital setting preferred.

- Experience with Medicare Advantage and HMO populations preferred.

- Experience with NCQA accreditation, quality improvement, HEDIS/Stars, or quality gap closure preferred.

If you are committed to putting our patients first and helping shape the future of care, you belong at Duly.

The compensation for this role includes a base pay range of $67,953.60- $101K with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person.