Impresiv Health
Description:
We are seeking a dedicated and detail-oriented Utilization Management Registered Nurse (UM RN) to support both inpatient and outpatient utilization review for a dynamic healthcare organization. This role requires strong clinical acumen, exceptional documentation skills, and deep familiarity with clinical criteria, including MCG guidelines, Medicare Advantage regulations, and LCD/NCD policies. Ideal candidates will bring robust experience across the utilization management spectrum-including preservice, concurrent, acute, and post-acute review processes-with a proven ability to apply evidence-based criteria confidently and consistently.
What You Will Do: Conduct preservice, concurrent, acute, and post-acute clinical reviews for inpatient, outpatient, and SNF services using evidence-based clinical criteria (e.g., MCG, InterQual, LCD/NCD) to assess medical necessity, appropriateness, and efficiency. Evaluate and process prior authorization (PA) requests in alignment with Medicare Advantage rules and organizational policy. Provide real-time clinical review support by collaborating with inpatient providers to guide timely decision-making and discharge planning. Apply clinical judgment and familiarity with complex case review processes to support seamless transitions across levels of care. Facilitate communication with case managers and interdisciplinary teams to ensure coordination, continuity, and timely delivery of services. Maintain precise, comprehensive documentation within platforms such as AcuityNxt and other electronic medical review systems. Monitor inpatient and SNF utilization trends, identifying areas for care optimization while maintaining compliance. Actively contribute to Transitions of Care (TOC) initiatives by supporting timely interventions that reduce readmissions and improve patient outcomes. Provide feedback and insights for continuous improvement and UM process enhancements.
You Will Be Successful If: You have strong, practical knowledge of clinical criteria and can confidently interpret and apply guidelines such as MCG, InterQual, LCD/NCD, and Medicare Advantage regulations to utilization review decisions. You bring hands-on experience with preservice, concurrent, acute, and post-acute review across diverse care settings. You are skilled at reviewing complex medical cases and navigating fast-paced clinical environments. You communicate clearly and effectively with healthcare teams, even in time-sensitive or high-pressure situations. You are comfortable working independently in a remote setting, meeting documentation and productivity benchmarks. You stay current on regulatory and guideline updates that impact UM decision-making.
What You Will Bring: Active, unrestricted Registered Nurse (RN) license (state-specific or compact license as required). Minimum of 3 years of experience in Utilization Management or clinical review, with direct experience applying clinical review criteria to real-world medical cases. Strong experience across preservice, concurrent, acute, and post-acute review workflows. In-depth knowledge of MCG guidelines, Medicare Advantage policies, and national/local coverage determinations (LCD/NCD). Experience with SNF and inpatient care management, TOC coordination, and prior authorization processes. Technical proficiency with UM systems, including AcuityNxt, and the ability to adapt quickly to new technology platforms. Strong attention to detail, organizational skills, and a commitment to accuracy, compliance, and ethical review practices. About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do - provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
What You Will Do: Conduct preservice, concurrent, acute, and post-acute clinical reviews for inpatient, outpatient, and SNF services using evidence-based clinical criteria (e.g., MCG, InterQual, LCD/NCD) to assess medical necessity, appropriateness, and efficiency. Evaluate and process prior authorization (PA) requests in alignment with Medicare Advantage rules and organizational policy. Provide real-time clinical review support by collaborating with inpatient providers to guide timely decision-making and discharge planning. Apply clinical judgment and familiarity with complex case review processes to support seamless transitions across levels of care. Facilitate communication with case managers and interdisciplinary teams to ensure coordination, continuity, and timely delivery of services. Maintain precise, comprehensive documentation within platforms such as AcuityNxt and other electronic medical review systems. Monitor inpatient and SNF utilization trends, identifying areas for care optimization while maintaining compliance. Actively contribute to Transitions of Care (TOC) initiatives by supporting timely interventions that reduce readmissions and improve patient outcomes. Provide feedback and insights for continuous improvement and UM process enhancements.
You Will Be Successful If: You have strong, practical knowledge of clinical criteria and can confidently interpret and apply guidelines such as MCG, InterQual, LCD/NCD, and Medicare Advantage regulations to utilization review decisions. You bring hands-on experience with preservice, concurrent, acute, and post-acute review across diverse care settings. You are skilled at reviewing complex medical cases and navigating fast-paced clinical environments. You communicate clearly and effectively with healthcare teams, even in time-sensitive or high-pressure situations. You are comfortable working independently in a remote setting, meeting documentation and productivity benchmarks. You stay current on regulatory and guideline updates that impact UM decision-making.
What You Will Bring: Active, unrestricted Registered Nurse (RN) license (state-specific or compact license as required). Minimum of 3 years of experience in Utilization Management or clinical review, with direct experience applying clinical review criteria to real-world medical cases. Strong experience across preservice, concurrent, acute, and post-acute review workflows. In-depth knowledge of MCG guidelines, Medicare Advantage policies, and national/local coverage determinations (LCD/NCD). Experience with SNF and inpatient care management, TOC coordination, and prior authorization processes. Technical proficiency with UM systems, including AcuityNxt, and the ability to adapt quickly to new technology platforms. Strong attention to detail, organizational skills, and a commitment to accuracy, compliance, and ethical review practices. About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do - provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!