Utilization Management Nurse

Job Summary

Detail-oriented and solutions-focused, the full-time remote Utilization Management Nurse will conduct clinical reviews of outpatient authorization requests, applying evidence-based medical necessity criteria and health plan policies to ensure members receive appropriate care.

Key responsibilities

• Conduct timely clinical reviews of outpatient authorization requests across various categories, ensuring compliance with CMS and Medicare Advantage requirements
• Determine the appropriateness of requested services and recommend clinically appropriate alternatives while maintaining accurate documentation
• Communicate with providers and internal teams to gather necessary clinical documentation and resolve inquiries, while meeting turnaround time standards

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 in a health plan or hospital setting
• Knowledge of CMS guidelines and Medicare Advantage requirements
• Experience in escalating cases and preparing clinical summaries for physician review
• Ability to thrive in a fast-paced environment with changing policies and criteria