Utilization Management Nurse (USRN) Medicare Advantage

Job Title

Utilization Management Nurse (USRN) – Medicare Advantage

Location

India / Philippines (Onsite and/or Remote)

Reporting To

Utilization Management Lead / Clinical Operations Manager

Role Overview

The Utilization Management Nurse (USRN) – Medicare Advantage is responsible for performing medical necessity reviews and utilization management activities for Medicare Advantage members. This role supports Prior Authorization, Concurrent Review, Retrospective Review, and Discharge Planning functions while ensuring compliance with CMS regulations, Medicare coverage policies, and payer-specific guidelines.

The incumbent will apply clinical expertise, MCG Care Guidelines, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs) to evaluate the appropriateness, medical necessity, and efficiency of healthcare services. The role requires close collaboration with providers, case managers, and medical directors to support quality outcomes, optimize healthcare utilization, and ensure regulatory compliance.

This position is critical in driving accurate utilization decisions, reducing avoidable costs, improving member outcomes, and maintaining CMS audit readiness.

Key Responsibilities

Prior Authorization Review

·      Review authorization requests for inpatient, outpatient, surgical, diagnostic, DME, rehabilitation, home health, and specialty services.

·      Evaluate clinical documentation to determine medical necessity and appropriateness of care.

·      Apply MCG Care Guidelines and Medicare coverage criteria to authorization decisions.

·      Approve cases within delegated authority and refer non-standard or complex cases to the Medical Director.

·      Ensure compliance with established turnaround times and service level agreements.

Concurrent Review

·      Conduct concurrent reviews for hospitalized members.

·      Assess continued stay requirements and appropriate level of care.

·      Monitor length of stay and identify opportunities for efficient discharge planning.

·      Collaborate with providers and case managers to facilitate transitions to appropriate care settings.

Retrospective Review

·      Conduct retrospective reviews to validate medical necessity and benefit coverage.

·      Evaluate healthcare utilization patterns and identify opportunities for process improvement.

·      Ensure compliance with Medicare Advantage policies and regulatory requirements.

Medical Necessity & Coverage Determination

·      Apply MCG Care Guidelines for inpatient, outpatient, and post-acute care reviews.

·      Interpret and apply CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

·      Review Medicare Parts A, B, and C coverage requirements when making utilization decisions.

·      Assess requests against clinical criteria, coverage policies, and benefit plan provisions.

Clinical Documentation Review

·      Analyze medical records, physician documentation, laboratory reports, imaging results, treatment plans, and discharge summaries.

·      Ensure clinical documentation adequately supports medical necessity determinations.

·      Maintain accurate, complete, and audit-ready documentation.

Provider Collaboration

·      Communicate with physicians, hospitals, provider offices, and case managers regarding authorization determinations.

·      Obtain additional clinical information when required.

·      Participate in peer-to-peer review coordination and case escalations.

Regulatory Compliance & Quality

·      Maintain compliance with CMS, Medicare Advantage, NCQA, and payer-specific requirements.

·      Adhere to HIPAA and healthcare privacy regulations.

·      Support internal quality audits and external regulatory audits.

·      Participate in continuous quality improvement initiatives.

Reporting & Performance Management

·      Meet productivity, quality, and turnaround time expectations.

·      Identify utilization trends and escalate concerns appropriately.

·      Participate in calibration sessions, quality reviews, and training programs.

Required QualificationsMandatory

·      Active and unrestricted US Registered Nurse (USRN) License.

·      Bachelor's Degree in Nursing (BSN) preferred.

·      Minimum 3–7 years of clinical nursing experience.

·      Minimum 2 years of Utilization Management experience supporting Medicare Advantage, Managed Care, or Commercial Health Plans.

·      Strong experience in Prior Authorization, Concurrent Review, and Retrospective Review.

·      Advanced knowledge of Medicare Advantage programs and CMS regulations.

·      Demonstrated expertise in MCG Care Guidelines.

·      Strong working knowledge of CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

·      Experience reviewing inpatient, outpatient, post-acute, SNF, home health, rehabilitation, imaging, and DME services.

·      Proficiency with utilization management platforms, EMRs, and payer systems.

·      Excellent verbal and written English communication skills.

Preferred

·      CCM (Certified Case Manager) Certification.

·      ACM (Accredited Case Manager) Certification.

·      Experience in Appeals and Grievances.

·      Exposure to Risk Adjustment and Population Health programs.

·      Prior experience supporting U.S. health plans or healthcare BPO operations.

Key Competencies

·      Medical Necessity Determination

·      Utilization Management Expertise

·      MCG Guidelines Proficiency

·      LCD/NCD Interpretation and Application

·      Medicare Advantage Compliance

·      Clinical Documentation Analysis

·      Critical Thinking and Clinical Judgment

·      Provider Communication and Collaboration

·      Audit Readiness and Documentation Accuracy

·      Productivity and SLA Management

Key Performance Indicators (KPIs)

·      Authorization Turnaround Time Compliance

·      Clinical Review Productivity

·      Quality Audit Scores

·      Medical Necessity Determination Accuracy

·      LCD/NCD Compliance Accuracy

·      Documentation Quality Scores

·      Regulatory Compliance Performance

·      Escalation and Peer Review Accuracy

·      Provider Satisfaction Metrics

Work Expectations

·      Flexible to work U.S. business hours.

·      Ability to manage high-volume review environments.

·      Mandatory completion of HIPAA, CMS, and compliance training.

·      Participation in ongoing clinical, regulatory, and utilization management education.

·      Willingness to cross-train across Medicare Advantage and related utilization management programs.

Career Path

·      Senior Utilization Management Nurse – USRN

·      Clinical Quality Auditor

·      UM Team Lead

·      Clinical Operations Manager