Utilization Management RN

Job Title: Utilization Review Nurse (Remote)

Pay Rate: $40/hr

Job Type: Full-Time, Remote

Benefits:

• 10 Paid Holidays
• 80 Hours of Paid Time Off (PTO)

Job Overview:
We are seeking an experienced, detail-oriented Utilization Review Nurse to join our team remotely. In this role, you will collaborate with healthcare providers and members to enhance quality care outcomes, optimize benefits, and promote effective resource use. You’ll ensure that care is medically appropriate, high-quality, and cost-effective by evaluating the medical necessity of services, treatments, and procedures, using the applicable medical policy and industry standards.

Key Responsibilities:

• Care Coordination: Conduct pre-certification, continued stay review, and discharge planning, ensuring treatment settings comply with criteria, medical policy, and member benefits.
• Resource Optimization: Assess the medical necessity of inpatient admissions, outpatient services, specialized surgical/diagnostic procedures, out-of-network services, and treatment appropriateness.
• Provider Collaboration: Partner with providers to identify and proactively plan for discharge, ensuring smooth transitions throughout the healthcare continuum.
• Claims Management: Collaborate with medical directors to interpret the appropriateness of care and facilitate accurate claims payment.
• Appeals Management: Oversee appeals for services denied, applying clinical expertise to achieve fair outcomes.
• Standards and Compliance: Support accreditation efforts by accurately applying regulatory standards and guidelines.
• Member Advocacy: Direct members to appropriate providers, programs, or community resources and ensure access to medically necessary, quality care in a cost-effective setting.

Qualifications:

• Education: High School Diploma or equivalent required.
• Licensure: Active, unrestricted RN license to practice within the applicable U.S. state(s) or territory.
• Experience: Minimum of 2 years of acute care clinical experience.
• Skills: Strong oral and written communication, problem-solving, facilitation, and analytical skills. Knowledge of accrediting and regulatory standards preferred for URAC-accredited areas.

Requirements:

• Reliable internet connection and remote workspace.
• Availability to consult with clinical reviewers and/or medical directors to maintain high-quality, cost-effective care standards.

If you are dedicated to supporting members and healthcare providers in achieving quality outcomes while optimizing resources, we encourage you to apply. This role is ideal for a skilled RN with a passion for medical management and a commitment to high standards in patient care.