State Licensed Utilization Management Nurse

Job Summary

Providing utilization management reviews, the full-time State Licensed Utilization Management Nurse will work remotely within Oregon, Washington, Idaho, or Utah, ensuring medical necessity and compliance while collaborating with interdisciplinary teams to enhance member care.

Key responsibilities

• Conduct utilization management reviews (prospective, concurrent, and retrospective) to assess medical necessity and adherence to policies
• Apply clinical expertise and evidence-based criteria for decision-making, consulting with physician advisors as necessary
• Collaborate with interdisciplinary teams to facilitate care transitions and resolve issues, while maintaining accurate documentation

Required qualifications

• Associate or Bachelor's Degree in Nursing or a related field
• Minimum of 3 years of experience in case management, utilization management, or related fields
• Current licensure or certification in a relevant health or human services discipline
• Experience providing direct clinical care for at least 3 years (or full-time equivalent)
• Must hold a current unrestricted RN license for medical care management or have a Bachelor's degree in a health-related field (preferred for behavioral health roles)