REMOTE UM Appeals Nurse (must live in NY state)- 253234

Job Title: Utilization Management Nurse (RN/LPN) – Clinical Appeals & Authorization (MUST HAVE NY RN LICENSE) Position Type: Full-Time Schedule: Monday–Friday, 40 hours per week Position Overview: We are seeking an experienced Utilization Management Nurse (RN/LPN) to support clinical review operations, appeals processing, and authorization management across inpatient, outpatient, and ancillary services. This role is responsible for evaluating medical necessity, determining appropriate level of care (LOC) and length of stay (LOS), and ensuring compliance with CMS, Medicare/Medicaid, and state regulatory requirements. The ideal candidate will bring strong clinical judgment, UM experience, and the ability to work collaboratively with providers, physician advisors, and external review agencies to ensure high-quality, compliant care management outcomes.

Utilization Management Operations: Perform inpatient admission certification, concurrent review, and outpatient/ancillary service authorizations Ensure all UM activities follow established clinical protocols, regulatory standards, and organizational policies Clinical Determination: Review cases for medical necessity, appropriate level of care (LOC), and length of stay (LOS) Utilize InterQual, CMS/Medicare Guidelines, and internal medical policies for evidence-based decision making Identify cases requiring escalation to Physician Advisors or Medical Directors Appeals Processing: Conduct clinical review of appeals against established criteria and regulatory requirements Prepare clinical summaries and recommendations for Physician Advisor review Ensure all appeal determinations meet strict turnaround times (TAT) External Liaison Coordination: Coordinate with External Review Agencies (ERA) and Clinical Peer Reviewers Ensure timely transmission of all external cases and proper documentation of final determinations within the system Documentation & Compliance: Maintain accurate and detailed records of clinical findings, review actions, and decision rationales Ensure documentation supports audit readiness and compliance with NCQA, URAC, CMS, and state requirements Member & Provider Engagement: Serve as a clinical liaison with Primary Care Physicians (PCPs) to obtain necessary medical documentation Communicate appeal outcomes and recommend appropriate treatment alternatives to members and providers Trend Analysis: Analyze pharmacy claims, encounter reports, and health risk assessments (HRA) to identify utilization trends and member care needs Support proactive interventions to improve care outcomes and cost containment