Connecticut Licensed Utilization Management RN

Job Summary

Working remotely on a full-time basis, the Connecticut Licensed Utilization Management RN will manage medical necessity reviews, authorization compliance, and reimbursement optimization while serving as a liaison between providers and payers.

Key Responsibilities

• Review documentation against payer policies and medical necessity criteria, identifying gaps and guiding improvements
• Interpret payer requirements and advise providers on compliance and discrepancies between authorized and performed services
• Prepare clinical summaries and medical necessity rationales for appeals, supporting provider preparation for discussions and identifying ways to prevent recurring denials

Required Qualifications

• Licensure as a Registered Nurse in the State of Connecticut or eligibility for Connecticut licensure
• Experience in utilization management, case management, prior authorization, or related healthcare operations preferred
• Knowledge of medical necessity criteria, payer guidelines, and healthcare reimbursement processes
• Strong critical thinking and clinical assessment skills
• Proficiency with electronic health records and payer portal systems