This position is a hybrid, on-site role in Franklin, TN!
American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I‑SNPs) for seniors who reside in long‑term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com .
Generous paid time‑off program and paid holidays for full‑time staff
TeleDoc 24/7/365 access to doctors
Optional short‑ and long‑term disability plans
Employee Assistance Plan (EAP)
401K retirement accounts with company match
Employee Referral Bonus Program
Job Summary
The Utilization Review Nurse is responsible for assessing the medical necessity and quality of healthcare services by conducting pre‑service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to ensure that members receive all appropriate medical services in compliance with medical and regulatory guidelines.
Essential Job Duties
Assess the medical necessity, quality of care, level of care and appropriateness of health‑care services for plan members
Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
Certify cases that meet clinical review criteria, guidelines and/or screens
Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
Refer cases to other professionals internally, including case management and medical consultation when indicated
Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
Other duties as assigned
Job Requirements
Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility
Encourage an atmosphere of optimism, warmth and interest in patients’ personal and health care needs
Develop and maintain collaborative relationships with providers and educate on levels of care
Ensure the integrity and high quality of utilization management services
Self‑motivated
Ability to work independently and as part of a team
Able to work congenially with a wide variety of individuals
Maintain the highest level of confidentiality and professionalism at all times
Strong oral and written communication skills, including active listening
Proficient in navigating through multiple computer applications
Positive, engaging customer service skills
Critical thinking and decision‑making skills
Successful completion of required training
Handle multiple priorities effectively
Independent discretion/decision making
Make decisions under pressure
Required Qualifications
Experience:
At least 1 year experience in utilization management with a health plan or hospital‑based UM department with use of Interqual or MCG
Prefer clinical experience
Broad knowledge of Medicare regulations and guidance
Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
Excellent customer service experience
Strong knowledge of medical terminology and CPT, ICD‑10, and HCPCS codes
Proven ability to problem‑solve and make solid decisions
License/Certification:
Current Certified Case Manager (CCM) credential is a plus
Current, active and unrestricted Registered Nurse (RN) license
EQUAL OPPORTUNITY EMPLOYER
This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.