Utilization Management Nurse

Job Description:

++Active Wisconsin RN license or Compact State required.++

We are seeking Utilization Management RNs to support a Medicare-focused population. This role will primarily handle medical-surgical reviews, with two RNs supporting inpatient concurrent reviews (members currently admitted or with emergent/urgent admissions) and one RN supporting outpatient procedural authorizations. This is a fully remote opportunity working Central Standard Time hours.

Responsibilities:

• Evaluate and process prior authorization requests and referrals from contracted and non-contracted providers.
• Perform pre-service, concurrent, and post-service utilization reviews following established policies and procedures.
• Verify eligibility and benefits and document all utilization management communications.
• Meet required production standards post-training (1.2 authorizations per hour / approximately 10 per 8-hour shift).
• Provide education regarding utilization management processes to members, caregivers, providers, and administrative staff.
• Participate in utilization management auditing activities, including inter-reviewer reliability and denial file audits.
• Issue denials as appropriate (approximately 23% denial rate for inpatient and outpatient).
• Utilize systems including Aerial, MCG, Medicare LCD/NCD, Coverage Documents, QNXT, Epic EMR, Microsoft Suite, and Teams.

Requirements:

• Associate Degree in Nursing required.
• Active Wisconsin RN license required.
• Minimum 4 years of clinical experience as a Registered Nurse.
• Experience with appeals, inpatient, and post-acute reviews required.
• Available to work Monday--Friday, 8:00am--4:30pm CST (remote).

Key Skills:

• Medicare utilization management
• Inpatient concurrent review
• Outpatient procedural review
• Prior authorization processing
• Medical necessity review (MCG, LCD/NCD)
• Appeals and denial management
• Strong documentation and compliance skills
• Proficiency with QNXT, Epic EMR, and Microsoft Office

Pay Range:

$40--43 per hour (contract)

Benefits:

Our comprehensive benefits package includes:

• Medical insurance
• Dental insurance
• Vision insurance
• 401(k) retirement savings plan

Contact:

Karrie Ruch kruch@jacobsongroup.com

Refer a Colleague:

Do you know someone who would be interested in this project? Submit your referral directly by emailing the Jacobson contact listed above or submitting them through this form. If your referral is hired for a contract assignment and meets all other eligibility criteria, you will receive a referral bonus!

Equal Opportunity Employer:

The Jacobson Group is committed to fostering an inclusive and equitable workplace that reflects the diverse communities we serve. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status or any other protected characteristic as defined by applicable law. We believe that diversity of thought, background and experience strengthens our team and drives innovation. All employment decisions are based on qualifications, merit and business needs.

If you require a reasonable accommodation to complete the application process or participate in an interview, please contact us at HR@jacobsononline.com or +1 (800) 466-1578 to make a request.