Utilization Management Nurse Coordinator

MEDIKO: Mission driven & committed to delivering high-quality medical care to the communities we serve.

Our dedicated Healthcare Professionals find meaning, support and new opportunities to learn and grow their skills every day. Its what sets us apart from other healthcare industries and drives our success in the correctional healthcare space.

Whether you are just graduating from nursing school or bringing years of experience to your new position at MEDIKO, you will benefit from our competitive compensation, commitment to safety and exposure to the diverse healthcare needs of the clients we serve.

If youre ready to take on a role that will enrich your career and make a real impact to your community, we encourage you to APPLY TODAY to get the conversation started!

Here are the Details -

Position: Utilization Management Nurse Coordinator

How YOU can make an Impact: (Job Responsibilities)

Utilization Management & Offsite Care Oversight

• Monitor and analyze UM data (e.g., offsite appointments, ER visits, hospital admissions, KPIs) to identify trends and recommend improvements.

• Coordinate and ensure timely completion of inpatient concurrent reviews and offsite service requests using nationally recognized, evidence-based criteria.

• Track hospitalizations to validate medical necessity, manage length of stay, and reduce avoidable admissions.

• Investigate client-reported incidents related to offsite care, including transportation issues and appointment disruptions.

Reporting & Stakeholder Communication

• Maintain accurate UM and offsite tracking reports in accordance with contractual and internal requirements.

• Prepare and present UM data reports to internal stakeholders and clients; lead monthly ER utilization reviews with nursing and operations teams.

• Provide statistical and financial impact data to support cost analysis of offsite services and identify non-billable days.

• Identify and coordinate care with outside hospitals and specialty providers as needed by facilities.

• Lead contracting efforts with hospitals and out-of-network providers to negotiate competitive rates and manage costs.

• Provider & Contract Management

Training & Onboarding

• Educate new facilities on UM processes during site onboarding.

• Oversee the HealthStream LMS: upload content, assign courses, track completion, and manage recurring trainings.

• Develop and deliver training content (e.g., videos, presentations, quizzes) to support ongoing staff development.

Compliance & Claims Support

• Ensure adherence to Medicaid and other regulatory billing requirements.

• Audit closed claims for accuracy and eligibility; resolve discrepancies and support Accounts Payable by reviewing funding requests and verifying required documentation.

• Provide claims status updates and guidance to internal stakeholders.

Leadership & Program Development

• Manage UM staff, including hiring, training, performance reviews, coaching, and retention.

• Provide leadership to Regional Care Managers and UM Schedulers; hold regular check-ins and performance evaluations.

• Lead UM process improvement initiatives and support development of programs to reduce inpatient length of stay and emergency department utilization.

• Establish and track progress toward UM program goals, including review timeliness, quality standards, and training outcomes.

• Maintain patient refusal and diversion tracking; report trends and concerns to regional or corporate leadership.

• Serve as liaison to client Clinical Quality and Patient Safety contacts, sharing relevant patient information for offsite services.

• Perform other duties as assigned.

What we ask of YOU: (Job Qualifications)

• Bachelors degree in a relevant field (e.g., Human Resources, Finance, Sales, Business Administration, Healthcare Administration, or related discipline) from an accredited institution preferred.

• Minimum of 2-3 years of relevant experience in the specific functional area (e.g., HR, Finance, Sales, Marketing, Operations, etc.).

• Experience in healthcare, correctional healthcare, or a regulated industry is preferred.

• Demonstrated success in applying function-specific skills (e.g., employee relations for HR, financial reporting for Finance, or sales strategy for Sales) is required.

• Knowledge of relevant industry-specific regulations, compliance standards, and best practices may be required, particularly for roles in highly regulated functions like HR and Finance.

• Relevant industry certifications based on the role (e.g., PHR, SHRM-CP, CPA, etc.).

• Active CPR/BLS certificate required (American Heart Association/American Red Cross guideline approved), if role is located in a correctional facility.

Joining MEDIKO comes with perks to support you in your personal and professional journey:

• Competitive Pay and MVP Bonus Program

• Benefits package including Medical, Dental, and Vision insurance for you and your family

• Preferred Pharmacy Network options

• MDLIVE virtual Provider telehealth options

• Wellness program

• Health Savings Accounts and Health Reimbursement Account options with company match

• Employer-paid Life Insurance Policy/AD&D, Long-Term Disability and Short-Term Disability coverage

• Optional Voluntary coverage for Life Insurance, Accident, Critical Illness, and Hospital Indemnity plans

• Paid portion of Maternity Leaves

• Employee Assistance Program

• Generous Paid Time Off (PTO) including 10 Holidays and flexible Floating Holidays

• Participation in the MEDIKO 401(k) Retirement Plan with company match

• Employee Referral Bonuses

• Tuition Reimbursement Assistance Plan

• Free Continuing Education

• Access to Perks and Discounts at nationally recognized chains, service providers and retailers

EOE STATEMENT: We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.