Maine Licensed Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse - Remote.

Key Responsibilities:

• Review prior authorization requests for medical necessity and collaborate with Medical Directors as needed
• Utilize evidence-based criteria and governmental policies for medical necessity reviews and manage claims disputes
• Coordinate transitions of care and referrals to Care Management while maintaining compliance with healthcare regulations

Required Qualifications:

• 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
• 2+ years of utilization management experience in a health plan UM department
• Compact RN License required
• Certification in managed care nursing or care management desired (CMCN or CCM)
• Coding/CPC certification desired