• Conduct reviews of medical records, treatment plans, and authorization requests to determine the medical necessity, appropriateness, and efficiency of healthcare services.
• Evaluate the clinical appropriateness of inpatient, outpatient, and other healthcare services in accordance with established guidelines and criteria.
• Collaborate with healthcare providers to discuss treatment plans, recommending alternatives when necessary to ensure the best possible care.
• Assist in the coordination of care for patients, ensuring that the treatment provided is medically necessary and delivered in the most appropriate setting.
• Participate in interdisciplinary team meetings to discuss complex cases and develop care plans that align with best practices.
• Ensure timely and accurate documentation of all utilization management decisions, maintaining confidentiality and compliance with HIPAA regulations.
• Utilize evidence-based clinical guidelines (such as InterQual, Milliman) to assess and determine medical necessity for various treatments and services.
• Work with healthcare providers to clarify requests and ensure they meet criteria for coverage and authorization.
• Serve as a liaison between healthcare providers, patients, insurance companies, and other stakeholders to facilitate the appropriate utilization of services.
• Communicate decisions effectively and explain the rationale for approvals, denials, and modifications of requested services.
• Provide education and guidance to healthcare providers and patients regarding utilization management policies and procedures.
• Ensure that utilization management practices comply with regulatory standards, accreditation requirements, and company policies.
• Assist with audits, quality improvement initiatives, and data collection efforts related to utilization management performance.
• Stay current on industry trends, healthcare regulations, and emerging clinical guidelines.
• Review and process appeal requests related to denials of service or coverage, working to resolve issues in a timely and thorough manner.
• Communicate with providers and insurance representatives to address denials and assist in resolving any disputes.

• Active, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of practice.
• Minimum of 3 years of clinical nursing experience in an acute care, outpatient, or similar healthcare setting.
• Experience in utilization management, case management, or healthcare insurance is highly preferred.
• In-depth knowledge of medical terminology, clinical practices, and healthcare regulations.
• Familiarity with utilization management software and medical review tools (e.g., InterQual, Milliman).
• Strong critical thinking, decision-making, and problem-solving abilities.
• Ability to work collaboratively with diverse teams and communicate effectively with healthcare providers, patients, and insurance carriers.
• Proficient in Microsoft Office Suite and electronic health record (EHR) systems.
• Strong attention to detail and organizational skills.
• Ability to manage multiple tasks and prioritize effectively in a fast-paced environment.
• Excellent interpersonal and communication skills, with a focus on customer service.
• Ability to work independently and make decisions based on established clinical guidelines.

AssureCare® is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.

This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and internship. AssureCare® makes hiring decisions based solely on qualifications, merit, and business needs at the time. Furthermore, the Company will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.