Care Manager – Utilization Management & Appeals (RN)

About the role

We are seeking an experienced Registered Nurse to join our Utilization Management Appeals team as a Care Manager. This full‑time contract role focuses on reviewing medical necessity, managing appeals, and supporting high‑quality patient outcomes across inpatient and outpatient settings in New York.

Key responsibilities

• Perform utilization management activities such as inpatient admission certification, concurrent review, discharge planning, and outpatient service review.
• Evaluate medical necessity, level of care, and length of stay using InterQual, CMS/Medicare guidelines, and internal policies.
• Review and process clinical appeals in partnership with Physician Advisors, ensuring regulatory turnaround times are met.
• Coordinate with External Review Agencies and Clinical Peer Reviewers to achieve timely case resolution.
• Maintain accurate documentation within UM/Appeals systems for compliance and audit readiness.
• Collaborate with primary care providers, members, and other clinicians to communicate appeal determinations and treatment alternatives.
• Identify utilization trends and member needs through data analysis, pharmacy claims review, and health assessments.
• Escalate complex cases to Physician Advisors or Medical Directors as needed.

Required profile

• Active, unrestricted RN license.
• Minimum 3 years of experience in Utilization Management, Clinical Appeals, Discharge Planning, or related care management functions.
• Experience in managed care or hospital settings with a focus on appeals or UM/UR.
• Strong knowledge of InterQual or MCG criteria and CMS/Medicaid/Medicare guidelines.
• Excellent clinical judgment, documentation, and communication skills.

Required skills

• InterQual
• MCG
• HealthEdge
• Jiva
• Salesforce Health Cloud

What we offer

• Full‑time contract through the end of the year.
• Opportunity to impact patient outcomes and healthcare costs.
• Collaborative environment with experienced clinical and operational teams.