North Carolina Licensed Utilization Nurse

Job Summary

Working remotely on a full-time basis, the North Carolina Licensed Utilization Nurse will perform medical necessity and benefit review requests, ensuring compliance with national standards and member benefit coverage.

Key responsibilities

• Conducts clinical utilization reviews using evidence-based guidelines and internal policies
• Collaborates with healthcare partners for timely service reviews and identifies potential quality of care issues
• Prepares cases for Medical Director oversight and communicates determinations to providers and members

Required qualifications

• Current Registered Nurse (RN) licensure in North Carolina
• Proficient in Microsoft Office applications
• 2+ years of experience in a Utilization Management team within a managed care setting
• Experience with inpatient and outpatient reviews, including Behavioral Health and Oncology cases preferred
• Working knowledge of URAC and NCQA standards