UM Appeals Nurse - 253234

Job Title: Utilization Management Nurse (RN/LPN) – Clinical Appeals & Authorization (MUST HAVE NY RN LICENSE) Position Type: Full-TimeSchedule: Monday–Friday, 40 hours per weekPosition OverviewWe 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.Key ResponsibilitiesUtilization Management OperationsPerform inpatient admission certification, concurrent review, and outpatient/ancillary service authorizationsEnsure all UM activities follow established clinical protocols, regulatory standards, and organizational policiesClinical DeterminationReview 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 makingIdentify cases requiring escalation to Physician Advisors or Medical DirectorsAppeals ProcessingConduct clinical review of appeals against established criteria and regulatory requirementsPrepare clinical summaries and recommendations for Physician Advisor reviewEnsure all appeal determinations meet strict turnaround times (TAT)External Liaison CoordinationCoordinate with External Review Agencies (ERA) and Clinical Peer ReviewersEnsure timely transmission of all external cases and proper documentation of final determinations within the systemDocumentation & ComplianceMaintain accurate and detailed records of clinical findings, review actions, and decision rationalesEnsure documentation supports audit readiness and compliance with NCQA, URAC, CMS, and state requirementsMember & Provider EngagementServe as a clinical liaison with Primary Care Physicians (PCPs) to obtain necessary medical documentationCommunicate appeal outcomes and recommend appropriate treatment alternatives to members and providersTrend AnalysisAnalyze pharmacy claims, encounter reports, and health risk assessments (HRA) to identify utilization trends and member care needsSupport proactive interventions to improve care outcomes and cost containmentRequired QualificationsActive, unrestricted RN or LPN licenseMinimum 3+ years of experience in Utilization Management, Discharge Planning, or Clinical AppealsStrong knowledge of CMS (Medicare/Medicaid) guidelines and state-mandated appeal timelinesProven clinical judgment with the ability to recognize cases requiring escalationRequired Technical SkillsDecision Support ToolsStrong working knowledge of InterQual or MCG for level-of-care determinationsUM/Appeals SystemsExperience with enterprise clinical platforms such as HealthEdge, Jiva, Salesforce Health Cloud, or similar systemsReporting & Data InterpretationAbility to analyze pharmacy claims, encounter data, and HRA databasesRegulatory PortalsExperience using secure portals for transmitting files to state and federal external review agenciesPreferred QualificationsCertified Case Manager (CCM) certificationABQAURP certificationExperience with Medicare Advantage, Managed Long-Term Care (MLTC), or Special Needs Plans (SNP)Prior experience handling External Appeals and working with regulatory bodies such as DOH or CMSSpecialized clinical background in Behavioral Health, Oncology, or Complex Surgical ServicesExperience conducting internal UM quality audits for NCQA or URAC complianceBilingual proficiency in a second language preferred