You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
our client is seeking an experienced Utilization Management Registered Nurse (UM RN) with strong knowledge of Skilled Nursing Facility (SNF) operations, Medicare, and Managed Long-Term Care (MLTC). This role will be responsible for reviewing clinical documentation, evaluating medical necessity, supporting appropriate levels of care, and ensuring services are aligned with payer guidelines and regulatory requirements.
The ideal candidate will have experience conducting utilization reviews within a SNF, health plan, managed care, or similar healthcare environment and be comfortable working with interdisciplinary teams, providers, and payers.
Key Responsibilities
- Conduct prospective, concurrent, and retrospective utilization reviews for SNF residents.
- Review clinical documentation to determine medical necessity, appropriateness of level of care, and continued stay.
- Apply Medicare, MLTC, Medicaid, and managed care guidelines when evaluating SNF services.
- Review admissions, continued stays, transfers, and discharge plans.
- Monitor length of stay and identify opportunities for appropriate transitions of care.
- Collaborate with physicians, nurse practitioners, social workers, case managers, therapists, and facility leadership.
- Communicate with health plans and managed care organizations regarding authorizations and continued stay determinations.
- Identify potential overutilization, underutilization, gaps in care, and barriers to discharge.
- Ensure clinical documentation supports the level of care and services being provided.
- Assist with appeals, reconsiderations, and medical necessity reviews as needed.
- Maintain accurate and timely documentation in accordance with organizational and regulatory requirements.
- Stay current with changes to Medicare, MLTC, Medicaid, and payer-specific utilization management requirements.
Qualifications
- Active, unrestricted Registered Nurse (RN) license.
- Strong communication, clinical judgment, and documentation skills.
- Ability to work independently while collaborating effectively with interdisciplinary teams.
Experience
- 3+ years of clinical nursing experience, preferably in a SNF, long-term care, managed care, utilization management, or case management environment.
- Direct experience with Medicare and MLTC populations.
- Experience performing chart reviews and/or utilization reviews.
- SNF utilization management or case management experience (Preferred).
- Experience working directly with MLTC plans and Medicare Advantage plans (Preferred).
- Familiarity with Medicare Part A SNF benefits, skilled coverage, authorizations, and continued stay reviews (Preferred).
- Experience with EMR systems and utilization management platforms (Preferred).
- Experience with appeals, denials, and peer-to-peer reviews (Preferred).
Skills
- Strong understanding of SNF levels of care, clinical documentation, medical necessity, and discharge planning.
- Application of Medicare, MLTC, Medicaid, and managed care guidelines.
- Knowledge of MDS, care plans, clinical criteria, and payer-specific guidelines.
Education
- Active, unrestricted Registered Nurse (RN) license.
- BSN preferred, but not required depending on experience.
Additional Requirements
- Schedule: M-F 9-5 (35 hours per week).
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
Any required state or Joint Commission training is compensated at the state or local minimum wage rate.
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
