UM​/UR & CDI Lead; RN

· Conduct medical necessity, admission, continued-stay, and patient status reviews using Inter Qual criteria, Medicare guidelines, and applicable payer policies.

· Evaluate clinical documentation, identify medical necessity gaps, and coordinate timely payer authorizations and physician escalations.

· Develop, implement, and standardize UM/UR workflows, best practices, and escalation processes to improve operational efficiency and regulatory compliance.

· Provide leadership, training, and mentorship to hospital Care Coordination/UR staff, promoting consistent review practices and effective interdisciplinary collaboration.

· Collaborate with physicians, case management, and hospital leadership to optimize utilization management, patient status accuracy, and length of stay.

· Monitor program performance, establish key performance indicators (KPIs), and develop utilization and length-of-stay reports to identify improvement opportunities.

· Support the development of early medical necessity review processes, including emergency department and admission workflows.

· Provide supplemental CDI support, including concurrent reviews, identification of documentation opportunities, compliant provider queries, and CDI cross-coverage as operationally needed.

Key Success Indicators/Attributes:

· Strong clinical judgment, critical thinking, and problem-solving skills.

· Ability to prioritize and multi-task in a multifaceted environment.

· Effective leadership, mentoring, and interdisciplinary communication skills.

· Demonstrate strong organizational skills and be detail oriented.

· Demonstrate ability to self-motivate, set goals, and meet deadlines.

· Demonstrate mentoring and interpersonal skills.

· Demonstrate excellent presentation, verbal, and written communication skills.

· Ability to develop and maintain relationships with key business partners by building personal credibility and trust.

· Maintains courteous and professional working relationships with employees at all levels of the organization.

· Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required.

· Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required

· Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

· Bachelor’s degree in nursing (BSN) or a healthcare related field.

· Active, unrestricted Registered Nurse (RN) license.

· 3-5 years of hospital-based Utilization Review/Utilization Management or care management experience, including medical necessity and patient status review.

·…