Registered Nurse (RN) - Mother Baby

Job Title: Registered Nurse (RN) | Case Manager – Utilization Review
Location: Atlanta, GA 30305
Duration: 3 + Months+ (Possible Extension)

Shift: 08:00 AM to 05:00 PM (Rotating weekends and holidays)
 
Summary:
Seeking an experienced Utilization Review RN to complete outpatient medical necessity reviews using evidence-based criteria. This role supports clinical decision-making, ensures appropriate levels of care, and collaborates with Medical Directors for escalations as needed.
 
Responsibilities:

• Perform medical necessity reviews for outpatient services using MCG, KP, and LCD criteria.
• Identify cases that require escalation and refer to the Medical Director as appropriate for potential denials.
• Ensure accurate documentation of review outcomes and clinical rationale.
• Collaborate with interdisciplinary teams to support timely patient care authorizations.
• Float to other departments as needed to support utilization management workflow.

 
Requirements:

• Active RN License (State of GA or Compact – Required)
• Minimum 2 years of Utilization Review or Case Management experience
• Experience with LCD (Local Coverage Determination) & MCG (Milliman Care Guidelines)
• BLS – American Heart Association