Utilization Management Nurse (USRN) – Medicare Advantage

India / Philippines (Onsite and/or Remote)

Utilization Management Lead / Clinical Operations Manager

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 director...