Lead RN, Utilization Management

Job Summary

Leading a team of clinical professionals, the remote Lead RN, Utilization Management will coach and develop staff, oversee daily review operations, and ensure compliance with clinical criteria and regulatory requirements while focusing on enhancing member outcomes.

Key responsibilities

• Lead, coach, and onboard Utilization Management nurses and clinical reviewers while supporting staff development through case audits and feedback
• Manage daily workloads and escalations across various review types, ensuring timely and accurate determinations
• Collaborate with Medical Directors on complex cases and oversee vendor performance, implementing corrective actions as needed

Required qualifications

• Active, unrestricted RN license
• Bachelor of Science in Nursing or equivalent relevant experience
• At least five years of clinical nursing experience and three years in health plan, managed care, or utilization management settings
• Experience leading, supervising, or mentoring clinical staff
• Understanding of medical-necessity review and clinical documentation, with familiarity in applying InterQual or MCG criteria