Utilization Management Registered Nurse

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🕒 5 days ago

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AppWorks

WebsiteLinkedInAll Job Openings

11 - 50 employees

Founded 2023

💼 Consulting

🏥 Healthcare

📦 Logistics

Consulting • Healthcare • Logistics

AppWorks is a global technology and professional services firm that partners with organizations to deliver AI-driven business transformation, high-performance technology solutions, and workforce talent services. The company provides strategy, design, and implementation across tech ecosystems, offers culture and leadership consulting through its Compass division, and supplies staffing and international talent services including visa sponsorship and placement from temporary to permanent roles.

📋 Description

• Conduct clinical reviews of inpatient, outpatient, and SNF services to assess medical necessity, appropriateness, and efficiency using evidence-based criteria (e.g., MCG). • Evaluate and process prior authorization (PA) requests in a timely, compliant manner. • Collaborate with inpatient providers and case managers to support Transitions of Care (TOC) and discharge planning. • Communicate clearly with interdisciplinary teams to ensure coordinated and effective care delivery. • Maintain accurate, comprehensive documentation in systems such as AcuityNxt and other electronic platforms. • Ensure compliance with Medicare Advantage, state, and federal healthcare regulations. • Contribute to process improvement initiatives to enhance overall UM effectiveness and efficiency.

🎯 Requirements

• Active, unrestricted RN license (state-specific or compact). • 3+ years of Utilization Management or related clinical review experience. • Proven experience with Skilled Nursing Facility (SNF) utilization reviews. • Strong familiarity with MCG criteria, LCD/NCD policies, and Medicare Advantage rules. • Prior experience in prior authorization (PA) and Transitions of Care (TOC) workflows. • Excellent clinical communication skills and confidence in engaging with inpatient providers. • Strong attention to detail, documentation accuracy, and compliance focus. • Tech-savvy with the ability to quickly adapt to healthcare systems and remote work tools.

🏖️ Benefits

• 100% Remote role – enjoy work-life balance while supporting patients across the continuum of care. • Collaborative, mission-driven healthcare environment. • Opportunity to expand into Transitions of Care (TOC) initiatives and process optimization. • Competitive compensation and benefits package.