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The Utilization Management (UM) Nurse supports appropriate level‑of‑care determination, patient flow, and revenue cycle integrity across inpatient, partial hospitalization, and intensive outpatient programs. The UM Nurse functions in two utilization management roles for coverage purposes utilization review/payor authorization and patient placement—ensuring continuity of operations, timely access to care, and optimal bed utilization.

Key Responsibilities include:

• Performs initial, concurrent, and continued‑stay utilization reviews to obtain and maintain third‑party payor authorization.
• Communicates clinical information to support medical necessity determinations and continued‑stay approvals.
• Serves as a liaison between payors and the interdisciplinary treatment team regarding authorization and level‑of‑care requirements.
• Tracks authorizations, follows up on denials, and supports appeal processes as needed.
• Collaborates with financial counseling and revenue cycle teams to support accurate reimbursement.
• Performs patient placement responsibilities as part of utilization management coverage.
• Assesses clinical acuity, level‑of‑care needs, and bed availability to support timely admissions and transfers.
• Monitors census and capacity to optimize bed utilization and patient flow.
• Completes required documentation accurately and timely in the electronic health record.
• Participates in quality improvement initiatives related to utilization management and patient flow.