RN Utilization Management Nurse

Job Summary

As a Clinical Guide on the Outpatient Utilization Management team, the full-time remote RN Utilization Management Nurse will conduct clinical reviews of outpatient authorization requests, applying evidence-based criteria and health plan policies to ensure members receive appropriate care.

Key responsibilities

• Conduct timely and comprehensive clinical reviews of outpatient authorization requests
• Determine the appropriateness of requested services and recommend clinically appropriate alternatives
• Communicate with providers and internal teams to resolve questions and obtain additional clinical documentation

Required qualifications

• An unrestricted RN license with a minimum of 4 years of RN experience
• At least 3 years of utilization management, utilization review, or prior authorization experience
• Knowledge of CMS guidelines and Medicare Advantage requirements
• Experience preparing clinical summaries for physician review
• Ability to thrive in a fast-paced environment with changing policies and criteria