Job Summary: The Utilization Management Nurse is responsible for a comprehensive clinical review to assess for medical necessity of outpatient and inpatient services, while maintaining compliance with all regulatory requirements. Work collaboratively with the Physician Advisor and Medicare Director of Care management in determining coverage of requested services; and in collaboration with other disciplines, provide planning and action for quality improvement.
Regulatory Requirements: Meets and maintains the minimum qualifications for the position including:
- Current State of Maine RN licensure.
- Three (3) or more years of previous experience in Utilization Management and/or Care Management.
- BSN preferred
· Certified Case manager required within 2 years of hire.