Utilization Management Registered Nurse (UM RN)
We are seeking an experienced and detail-oriented Utilization Management Registered Nurse (UM RN) to join our hospital team. The UM RN is responsible for reviewing patient cases to ensure appropriate utilization of healthcare services, medical necessity, compliance with payer requirements, and optimal patient outcomes. This role collaborates closely with physicians, case managers, and interdisciplinary teams to support quality patient care while managing healthcare resources efficiently.
Perform utilization review activities for inpatient and outpatient services.
Assess medical necessity, level of care, and appropriateness of admissions using established criteria such as InterQual or MCG guidelines.
Collaborate with physicians, case management, and healthcare teams regarding patient care plans and discharge planning.
Communicate with insurance providers and third-party payers to obtain authorizations and resolve coverage issues.
Monitor patient length of stay and identify opportunities to improve care efficiency.
Ensure compliance with hospital policies, federal regulations, and payer requirements.
Document utilization review findings accurately and maintain confidentiality of patient information.
Participate in denial prevention and appeals processes when necessary.
Support quality improvement initiatives and patient care coordination activities.
Active Registered Nurse (RN) license in the applicable state.
Bachelor of Science in Nursing (BSN) preferred.
Minimum 2–3 years of acute care hospital nursing experience required.
Prior experience in Utilization Management, Case Management, or Care Coordination preferred.
Strong knowledge of InterQual and/or MCG criteria.
Experience working with electronic medical records (EMR) systems.
Excellent communication, critical thinking, and organizational skills.
Central Business Solutions Inc (CBS), founded in 2000 and headquartered in Newark, California, has carved a niche for itself in the global business solutions market. Our experience spans across various industries, serving both small businesses and Fortune 500 companies. Here's a breakdown of our core offerings:
Technology Solutions: CBS acts as your IT department's backbone, offering a comprehensive suite of services. We provide expert guidance on crafting a technology strategy that aligns with your business goals. This includes consulting on system architecture and implementation, ensuring your infrastructure is built for efficiency and scalability. Our expertise extends to software development, crafting custom solutions or integrating existing ones to streamline operations. But CBS doesn't stop at setup; we also provide ongoing maintenance and support to keep your technology running smoothly.
Outsourcing: Whether you need to supplement your existing IT staff or completely outsource your IT department, CBS offers flexible solutions. We can provide qualified personnel to handle specific tasks like software development, UI/graphic design, or recruitment. Alternatively, we can take over the entire IT management responsibility, freeing your internal team to focus on core business functions.
Consulting: Our expertise extends beyond technology. CBS offers consulting services to help you achieve your overall business goals. Our team of experienced professionals can analyze your operations and identify areas for improvement. We'll develop data-driven strategies to streamline processes, enhance efficiency, and ultimately deliver bottom-line results.
In essence, Central Business Solutions Inc goes beyond just being a vendor. We position ourselves as a strategic partner for businesses. By combining our IT prowess with business acumen, we help clients optimize technology infrastructure, streamline operations, and achieve sustainable success.
