Registered Nurse-Review Analys New

Inpatient Precertification Nurse (RN) – Utilization Management

Location

Michigan (Remote)

May be required to come into the office for meetings and training.

Schedule

Offsite / Remote

Type

Full-Time Ongoing Contract (12 Months, Likely Extension)

Summary

Join our client’s MA Inpatient Precertification team and support high-quality patient care through comprehensive utilization review. In this role, you will conduct prospective, concurrent, and retrospective reviews across inpatient, outpatient, ambulatory, and ancillary services. Your work ensures medical necessity, appropriate level of care, and compliance with health plan requirements. You will collaborate with providers, facilities, and members—helping guide care plans and coordinating services across the continuum.

Key Responsibilities

• Perform medical necessity reviews for inpatient, outpatient, ambulatory, and ancillary services.
• Evaluate appropriate length of stay, intensity of service, and level of care to support authorization decisions.
• Conduct prospective, concurrent, and retrospective reviews, including appeals initiated by providers, facilities, or members.
• Establish care plans and coordinate services across the healthcare continuum, including member outreach and assessments.
• Ensure thorough documentation and adherence to UM guidelines and healthcare delivery processes.
• Utilize strong clinical judgment to support determinations and contribute to quality outcomes.
• Collaborate with internal teams, providers, and external partners to ensure continuity of care.
• Apply above?average computer skills to manage documentation, Microsoft Office tasks, and electronic review systems.
  
  

Required Qualifications

• Registered Nurse (RN) – Current, unrestricted Michigan license (Required).
• Bachelor’s degree in Nursing, Allied Health, Business, or related field (Preferred).
• 2–4 years of clinical experience (acute care, ICU, ER, medical-surgical, discharge planning, case management, utilization review, etc.).
• Demonstrated understanding of patient care workflows and healthcare delivery processes.
• Above-average computer skills, including Microsoft Office.
• 1+ year health plan or managed care experience (Preferred).
• Utilization Management experience strongly preferred.
• Case Management certification may be preferred depending on department needs.
  
  

Preferred Qualifications

• Clinical experience in ICU, ER, or Medical-Surgical settings.
• Previous utilization review / utilization management experience.
• Strong analytical and decision-making skills with the ability to interpret clinical information.
• Excellent communication skills for interacting with members, providers, and internal teams.