Contract Utilization Management Nurse

About IntusCare IntusCare is the only end-to-end ecosystem built specifically to help Programs of All-Inclusive Care for the Elderly (PACE) programs deliver exceptional care, strengthen financial performance, and stay compliant. IntusCare replaces outdated technology and manual workarounds with purpose-built solutions for care coordination, risk adjustment, population health, and utilization management. IntusCare empowers teams to take control of their operations and improve outcomes for dual-eligible seniors – some of the most socially vulnerable and clinically complex individuals in the US healthcare system. Role Overview The Contract Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This individual partners closely with PACE Interdisciplinary Teams, Medical Directors, and provider networks to review service utilization, guide care decisions and support timely, appropriate transitions across care settings. Blending clinical expertise with analytical thinking, the Utilization Management Nurse ensures services are medically necessary, aligned with care plans and consistent with PACE regulations and best practices. This role is essential to maintaining program integrity, improving participant outcomes and supporting the delivery of coordinated, value-based care. Responsibilities Rigorous adherence to PACE program service authorization policies, ensuring that participant care and related claims are: Reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions. In accordance with accepted medical standards and consistent with the participant care needs including level of care and advanced care planning principles. Active involvement in various aspects of the utilization management process, including: Concurrent review of all hospital admissions (observation and inpatient) with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization. Concurrent review of all subacute and SNF adm issions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care. Coordination and review of all other services delivered by contracted providers and identified by the PACE program assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions. Employ effective use of knowledge, critical thinking, and skills to: Advocate quality care and enhanced quality of life Advocate decreased hospital stay when appropriate Maintain accurate records of all patient related interactions Appeal Management - In cases of claim rejection, the IntusCare Utilization Management Nurse will lead the provider appeals process. Responsibilities Include: Comprehensive review of provider network appeals.