USRN Case Manager Nurse

Qualifications and Key Requirements

• Active US Registered Nurse (RN) license; New York State RN license preferred.

• Minimum 2+ years of recent bedside clinical experience in an acute care hospital setting.

• Minimum 2+ years of experience in Utilization Management (UM), Prior Authorization, Denials Management, or Appeals Review.

• Extensive experience handling inpatient medical necessity appeals across Commercial, Medicare, Medicaid, and Managed Care payers.

• Strong knowledge of inpatient authorization denials, medical necessity denials, level-of care determinations, procedure denials, medication denials, and retrospective reviews.

• Proficient in MCG, InterQual, CMS Medicare Guidelines, and commercial payer medical policies.

• Experience with first-level appeals, second-level appeals, reconsiderations, Peer-to-Peer (P2P) reviews, and medical necessity appeal letters.

• Knowledge of medical terminology, ICD-10, CPT, and basic coding concepts.

• Excellent written and verbal communication skills with physicians, payers, case managers, and leadership teams.

• Proficient in EMR systems, Microsoft Office, payer portals, and utilization management platforms.