RN Utilization Management

Job Summary

Working remotely, the full-time RN Utilization Management will review and document member case histories and prior authorization requests, utilizing clinical judgment to determine coverage eligibility while ensuring compliance with policies and procedures.

Key Responsibilities:

• Review and document prior authorization requests and member case histories for coverage approval
• Analyze trends through case reviews and recommend revisions to medical policies and utilization management processes
• Interface with members, providers, and internal departments to facilitate utilization review activities

Required Qualifications:

• Bachelor's degree or equivalent experience in a related field
• 5 years of work experience beyond degree
• Active LPN or RN license