Position Title: Utilization Review Nurse – Post-Acute Care
Work Location: Remote
Assignment Duration: 3 months
Work Arrangement: Remote

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Position Summary:
The Utilization Review Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of post-acute care services, including inpatient rehabilitation, skilled nursing facility and long-term acute care levels of care.
This role ensures alignment with evidence-based guidelines, regulatory requirements and organizational policies while promoting optimal patient outcomes and cost-effective care.

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Background & Context:
Managed care setting focused on post-acute care utilization and cost-effective outcomes.

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Key Responsibilities

• Conduct utilization review for post-acute care services, including:
o Inpatient Rehabilitation Facilities (IRF)/Acute Rehab
o Skilled Nursing Facilities (SNF)/Subacute Nursing Facilities
o Long-Term Acute Care Hospitals (LTAC)

• Review clinical documentation to determine medical necessity, level of care, and length of stay using approved criteria (e.g., InterQual and internal medical policies).

• Perform:
o Prior authorization reviews
o Concurrent reviews
o Retrospective reviews as needed

• Collaborate with providers, case managers, and interdisciplinary teams to ensure appropriate care planning and transitions of care.

• Communicate determinations (approvals, denials, modifications) clearly and timely to providers and stakeholders.

• Identify cases that require escalation to Medical Directors and participate in discussions with Medical Director when appropriate.

• Monitor ongoing cases for continued stay criteria and discharge readiness.

• Ensure compliance with:
o CMS guidelines
o State and federal regulations
o NCQA Accreditation standards

• Document all review activities accurately in the utilization management system.

• Participate in quality improvement initiatives and audits related to utilization management and post-acute care.

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Qualification & Experience

Education:
• Active, unrestricted Registered Nurse (RN) license
• Bachelor of Science in Nursing (BSN) preferred

Experience:
• 3–5 years of clinical nursing experience required
• Previous experience in a managed care organization required
• Prior experience in utilization review, case management, or discharge planning preferred
• Strong background in post-acute care settings (IRF, SNF, LTAC) highly desirable

Knowledge & Skills:
• Familiarity with utilization review criteria (InterQual)
• Knowledge of post-acute levels of care and admission criteria
• Understanding of managed care principles and reimbursement models
• Strong clinical assessment and critical thinking skills
• Excellent communication and negotiation abilities
• Proficiency in electronic medical records and UM systems

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 45.00/daily.