Utilization Management Nurse

This is a fully remote position, open to applicants in Arizona, +13 more states.

📋 Description

• Conducts clinical utilization reviews utilizing evidence-based guidelines, policies, nationally recognized clinical criteria, and internal procedures.

• Recognizes potential Third-Party Liability and Coordination of Benefit Cases, notifying the relevant parties and departments.

• Works in collaboration with healthcare partners to ensure prompt review of services and care.

• Refers cases to Case Management, Disease Management, Appeals & Grievances, and Quality Departments as required.

• Develops and reviews member-centric documentation and correspondence reflecting determinations, ensuring compliance with regulatory and accreditation standards.

• Identifies potential quality of care issues, service or treatment delays, and intervenes as clinically appropriate.

• Triages and prioritizes cases as well as other assigned tasks to meet necessary turnaround times.

• Prepares and presents cases to the Medical Director (MD) for oversight and necessity determinations.

• Communicates determinations to providers and/or members in accordance with regulatory and accreditation requirements.

• Performs additional duties as assigned.

⛳️ Requirements

• Current Licensed Practical Nurse (LPN) with state licensure, maintaining active and unrestricted licensure throughout employment.

• Proficient in Microsoft Office applications (Outlook, Word, Excel, and PowerPoint).

• Capable of working independently.

• Detail-oriented with strong organizational and time management skills.

• Adaptable to a fast-paced and changing environment, demonstrating flexibility in assignments.

• Proficient in the Utilization Review process, including benefit interpretation, contract language, and medical and policy reviews.

• Familiar with MCG and CMS criteria sets.

• Preferred experience includes both inpatient and outpatient reviews, covering areas such as Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases.

• Working knowledge of URAC and NCQA standards.

• A minimum of 2 years’ experience in a Utilization Management team within a managed care setting.

• Preferred 3+ years’ experience in a clinical nursing setting.

• Experience with TPA is a plus.

🏝️ Benefits

• Health insurance

• 401(k) matching

• Flexible work hours

• Paid time off