Utilization Review Nurse

This is a fully remote position, open to applicants in Oregon.

📋 Description

• Conduct clinical evaluations and prior authorizations to assess medical necessity.

• Forward complicated cases to Medical Directors and request any necessary documentation.

• Work collaboratively with care coordinators, discharge planners, and interdisciplinary teams to facilitate care transitions.

• Coordinate with internal departments to address eligibility, benefits, or service-related issues.

• Engage in discharge planning for members moving from acute, long-term, or residential care settings.

• Execute audits and assist in quality improvement initiatives.

• Provide training and mentorship on Utilization Management (UM) protocols and workflows.

• Foster relationships with community providers and service organizations.

• Ensure adherence to organizational policies, clinical standards, and federal/state regulations.

• Carry out other nursing-related responsibilities as assigned.

⛳️ Requirements

• Valid, unrestricted RN license (BSN or MSN) in Oregon or a compact state.

• Graduation from an accredited nursing program.

• At least 5 years of direct patient care experience.

• Proficient in Microsoft Office, EHR systems, and UM software.

• Strong clinical expertise, communication, and organizational abilities.

• No history of suspension, exclusion, or debarment from federal healthcare programs.

🏝️ Benefits

• Comprehensive benefits package that includes vacation PTO, sick leave, federal holidays, and birthday leave.

• Medical, dental, and vision insurance coverage.

• 401(k) plan with company matching (fully vested immediately).

• Company-sponsored life insurance along with additional benefits.

• Fitness reimbursement program.

• Tuition reimbursement and more.