Utilization Management Experienced

2 weeks ago

India SHAI Full time

Job Description Job Title: Process Analyst Utilization Management (UM) Nurse Location: Chennai Job Description: We are looking for a clinically experienced and detail-oriented Utilization Management (UM) Nurse to join our healthcare operations team as a Process Analyst in Chennai. In this role, you will leverage your nursing background to conduct clinical reviews, support utilization managementactivities, and contribute to case management operations. You'll play a key role in promoting medically necessary, cost-effective care in accordance with U.S. healthcare guidelines. This position is ideal for Registered Nurses (RNs) seeking for transition from bedside care into a non-clinical, operations-focused role, while continuing to make a direct impact on healthcare quality and outcomes. Key Functions: Conduct clinical reviews and assessments of medical service requests across various care settings (inpatient, outpatient, home health, behavioral health, DME, Infusions/Injectable) to determine medical necessity. Support utilization review activities using evidence-based guidelines (e.g., MCG) to facilitate authorization decisions. Collaborate with case management teams to assist in care planning, discharge coordination, and continuity of care. Validate prior authorization requirements and support approvals based on eligibility, clinical documentation, and payer criteria. Review insurance and clinical documentation to ensure compliance with U.S. healthcare policies (Medicare, Medicaid, Commercial, and Managed Care plans). Review denial letters issued by health plans and analyze if the treatment provided aligns with established guidelines and create a supportive summary to effectively appeal the denial and advocate for appropriate payment. Collaborate with Prior authorization team and generate denial letters to the member's based on the Denial justification. Partner with data and operations teams to track utilization trends and identify opportunities for workflow optimization. Participate in quality improvement initiatives, audits, and regulatory reporting. Maintain accurate, compliant clinical documentation in alignment with organizational standards. Qualifications: Bachelor's /Master's degree in Nursing Clinical experience in hospital, insurance, or care coordination settings is an asset. Knowledge of U.S. healthcare systems, including Medicare, Medicaid, and commercial insurance. Familiarity with clinical guidelines, patient care pathways, and utilization review tools such as MCG is advantageous. Strong analytical, critical thinking, and documentation skills. Proficiency in Microsoft Office applications, particularly Excel and Word. Excellent verbal and written communication skills. Ability to work independently and effectively in a fast-paced, dynamic environment. Shifts: Day (timings) Night (timings) 2100-0600 5 days working per week. Weekend/Rotational support based on client requirements.

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