RN- Utilization Review/Case Manager
Detroit, MI- seeking local candidates only. Looking for 2-4 years of RN experience. This role is a Registered Nurse – Utilization Review/Case Management professional responsible for evaluating healthcare services to ensure medical necessity, appropriate level of care, and cost-effective treatment across inpatient and outpatient settings. The position includes utilization review, appeals handling, care coordination, and discharge planning, while ensuring compliance with regulatory standards. 1. Active unrestricted Michigan Registered Nurse (RN) license 2. Clinical Experience (2–4 Years)
- Experience in one or more of the following:
- Acute patient care
- Case management
- Discharge planning
- Utilization review
___________________________________________________________________________________ 3. Utilization Review & Medical Necessity Skills
- Ability to Evaluate level of care and length of stay and apply clinical guidelines for medical necessity
4. Regulatory & Compliance Knowledge
- Understanding of Healthcare regulations (state and federal) and Accreditation standards (e.g., NCQA
__________________________________________________________________________________ 5. Care Coordination & Discharge Planning
- Ability to Coordinate care across multiple providers and settings and Manage transitions throughout the care continuum
____________________________________________________________________________________ 6. Technical Skills
- Proficiency in Microsoft Office (Word, Excel, Outlook) and Documentation and case management systems
7. Problem-Solving & Issue Resolution
- Ability to Resolve benefits, eligibility, and authorization issues and navigate complex cases including out-of-network situations
Preferred Qualifications
Bachelor’s Degree (Nursing, Allied Health, Business, or related field) 1+ year of Managed Care / Health Plan Experience Pay: $33.00 - $35.00 per hour Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Experience:
- RN Case Management: 3 years (Required)
- Utilization review: 1 year (Required)
- Regulatory and compliance : 2 years (Required)
- discharge planning: 2 years (Required)
Location:
- Michigan (Required)
Work Location: Remote