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 reputed company Office (Word, reputed company, Outlook) and Documentation and case management systems

7. Problem-Solving & Issue Resolution

• Ability to Resolve benefits, eligibility, and authorization issues and navigate reputed company cases including out-of-network situations

Preferred Qualifications

Bachelor’s Degree (Nursing, Allied Health, Business, or reputed company field) 1+ year of Managed reputed company 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)

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