REMOTE UM Appeals Care Manager (RN or LPN) - 253234

Medix provides workforce solutions to clients and creates opportunity for talent in the Healthcare, Life Sciences, Engineering and Technology fields. Through our core purpose of positively impacting lives, we have earned our reputation as an industry leader by providing unsurpassed customer service and top quality professionals to our clients.

Utilization Management Nurse (RN/LPN) – Managed Care / Appeals & Authorization (Remote) Overview: We are seeking an experienced and detail-oriented Utilization Management Nurse to support clinical review operations within a fast-paced managed care environment. This role is responsible for conducting medical necessity reviews, processing appeals, coordinating with providers and external review agencies, and ensuring compliance with CMS and state regulatory requirements. The ideal candidate will bring strong clinical judgment, utilization management expertise, and the ability to navigate complex cases while maintaining exceptional documentation standards.

Utilization Management Operations: Perform inpatient admission certification, concurrent review, and outpatient/ancillary authorization reviews. Evaluate medical necessity, level of care (LOC), and length of stay (LOS) using InterQual, CMS/Medicare guidelines, and internal medical policies. Ensure all reviews and determinations are completed within required turnaround times (TATs). Appeals & Clinical Review: Review clinical appeals and summarize findings for Physician Advisor or Medical Director review. Coordinate external appeal processes with External Review Agencies (ERA) and Clinical Peer Reviewers. Ensure timely submission of external review documentation and accurate implementation of final determinations. Documentation & Compliance: Maintain accurate and audit-ready documentation within UM and Appeals platforms. Document clinical findings, decision rationales, and review outcomes in accordance with regulatory and accreditation standards. Support compliance with CMS, NCQA, URAC, and state-mandated guidelines. Provider & Member Collaboration: Partner with PCPs and providers to obtain clinical information necessary for case review. Communicate authorization and appeal determinations to providers and members. Educate stakeholders on appropriate treatment alternatives and next steps when applicable. Reporting & Trend Analysis: Analyze pharmacy claims, encounter data, and health risk assessments to identify utilization trends and member needs. Escalate complex or high-risk cases appropriately to Physician Advisors or Medical Directors.