North Carolina Licensed Utilization Nurse

Job Summary

To support its clients, the full-time North Carolina Licensed Utilization Nurse will perform medical necessity and benefit review requests remotely, ensuring compliance with national standards and contractual requirements.

Key responsibilities

• Conducts clinical utilization reviews using evidence-based guidelines and internal policies
• Collaborates with healthcare partners to ensure timely review of services and care
• Identifies potential quality of care issues and communicates determinations to providers and members

Required qualifications

• Current Licensed Practical Nurse (LPN) with active and unrestricted state licensure
• 2+ years of experience in a Utilization Management team within a managed care setting
• Proficient in Microsoft Office applications
• Experience with inpatient and outpatient reviews, including Behavioral Health and elective surgical cases
• Working knowledge of URAC and NCQA standards