Utilization Review Nurse, RN

This is a fully remote position, open to applicants in Alabama, +25 more states.

📋 Description

• Perform prior authorization, inpatient review, concurrent review, retrospective review, medical director referrals, and issue member/provider approval or denial letters.

• Evaluate provider service requests that necessitate authorization.

• Execute pre-certification, continued stay review, care coordination, and discharge planning.

• Assess the appropriateness of treatment settings and ensure compliance with relevant criteria, medical policies, member eligibility, benefits, and contracts.

• Oversee appeals for services that have been denied.

• Provide both written and verbal notifications to members and providers.

• Engage in proactive anticipatory discharge planning.

• Act as a joint transition-of-care coordinator alongside case management and facilitate member care transitions.

• Ensure medical director decisions align with CMS, state regulations, medical policies, and clinical criteria.

• Support accreditation efforts by accurately applying accrediting and regulatory requirements and standards.

⛳️ Requirements

• Registered Nurse (RN) License (Compact or Virginia) is REQUIRED.

• Minimum of 3 years of acute care clinical experience is REQUIRED.

• Prior experience in Utilization Review is highly preferred.

• Previous experience with LTSS Waiver or Medicaid is highly preferred.

• Familiarity with InterQual or Milliman is preferred.

• Knowledge of NCQA standards is preferred.

• Excellent oral, written, and interpersonal communication skills.

• Strong problem-solving, facilitation, and analytical capabilities.

• Proficient in Microsoft applications, including Word, Excel, Outlook, and Teams.

• Bachelor’s Degree in Nursing is preferred.

• Available for standard hours of 8am to 5pm EST, Monday through Friday.

• Weekend and holiday coverage is required.

• Expected to work 13 weekend day shifts annually and be assigned holiday coverage.

• Must be able to work in one of the eligible states listed.

🏝️ Benefits

• Medical, Dental, and Vision plans.

• Adoption, Fertility, and Surrogacy Reimbursement up to $10,000.

• Paid Time Off and Sick Leave.

• Paid Parental & Family Caregiver Leave.

• Emergency Backup Care.

• Long-Term, Short-Term Disability, and Critical Illness plans.

• Life Insurance.

• 401k/403B with Employer Match.

• Tuition Assistance of $5,250/year and discounted educational opportunities through Guild Education.

• Student Debt Pay Down of $10,000.

• Pet Insurance.

• Legal Resources Plan.

• Opportunity to earn an annual discretionary bonus based on established system and employee eligibility criteria.

• Market-competitive compensation packages that include base pay, incentives, and benefits.

• Commitment to professional development and continued employment philosophy.