Remote UM Appeals Nurse – 253234 (LPN/LVN, RN)

Job Title: Utilization Management Nurse (RN/LPN) – Clinical Appeals & Authorization (MUST HAVE NY RN LICENSE)

Position Type: Full-Time

Schedule: Monday–Friday, 40 hours per week

Position Overview

We are seeking an experienced Utilization Management Nurse (RN/LPN) to support clinical review operations, appeals processing, and authorization management across inpatient, outpatient, and ancillary services. This role is responsible for evaluating medical necessity, determining appropriate level of care (LOC) and length of stay (LOS), and ensuring compliance with CMS, Medicare/Medicaid, and state regulatory requirements.

The ideal candidate will bring strong clinical judgment, UM experience, and the ability to work collaboratively with providers, physician advisors, and external review agencies to ensure high-quality, compliant care management outcomes.

Key Responsibilities

Utilization Management Operations

• Perform inpatient admission certification, concurrent review, and outpatient/ancillary service authorizations
• Ensure all UM activities follow established clinical protocols, regulatory standards, and organizational policies

Clinical Determination

• Review cases for medical necessity, appropriate level of care (LOC), and length of stay (LOS)
• Utilize InterQual, CMS/Medicare Guidelines, and internal medical policies for evidence-based decision making
• Identify cases requiring escalation to Physician Advisors or Medical Directors

Appeals Processing

• Conduct clinical review of appeals against established criteria and regulatory requirements
• Prepare clinical summaries and recommendations for Physician Advisor review
• Ensure all appeal determinations meet strict turnaround times (TAT)

External Liaison Coordination

• Coordinate with External Review Agencies (ERA) and Clinical Peer Reviewers
• Ensure timely transmission of all external cases and proper documentation of final determinations within the system

Documentation & Compliance

• Maintain accurate and detailed records of clinical findings, review actions, and decision rationales
• Ensure documentation supports audit readiness and compliance with NCQA, URAC, CMS, and state requirements

Member & Provider Engagement

• Serve as a clinical liaison with Primary Care Physicians (PCPs) to obtain necessary medical documentation
• Communicate appeal outcomes and recommend appropriate treatment alternatives to members and providers

Trend Analysis

• Analyze pharmacy claims, encounter reports, and health risk assessments (HRA) to identify utilization trends and member care needs
• Support proactive interventions to improve care outcomes and cost containment

Required Qualifications

• Active, unrestricted RN or LPN license
• Minimum 3+ years of experience in Utilization Management, Discharge Planning, or Clinical Appeals
• Strong knowledge of CMS (Medicare/Medicaid) guidelines and state-mandated appeal timelines
• Proven clinical judgment with the ability to recognize cases requiring escalation

Required Technical Skills

Decision Support Tools

• Strong working knowledge of InterQual or MCG for level-of-care determinations

UM/Appeals Systems

• Experience with enterprise clinical platforms such as HealthEdge, Jiva, Salesforce Health Cloud, or similar systems

Reporting & Data Interpretation

• Ability to analyze pharmacy claims, encounter data, and HRA databases

Regulatory Portals

• Experience using secure portals for transmitting files to state and federal external review agencies

Preferred Qualifications

• Certified Case Manager (CCM) certification
• ABQAURP certification
• Experience with Medicare Advantage, Managed Long-Term Care (MLTC), or Special Needs Plans (SNP)
• Prior experience handling External Appeals and working with regulatory bodies such as DOH or CMS
• Specialized clinical background in Behavioral Health, Oncology, or Complex Surgical Services
• Experience conducting internal UM quality audits for NCQA or URAC compliance
• Bilingual proficiency in a second language preferred