Utilization Review Nurse New

Job Title: Utilization Management RN

Location: Remote in the following states ONLY: IL, TX, MT, OK, NM, and TN

Job Type: W2 Contract

Expected hours per week: 40 hours per week

Schedule: Mon-Fri 8am-5pm

Pay: $ 41.00 per hour

Job Summary

The Registered Nurse, Utilization Management (UM) is responsible for collaborating with healthcare providers, members, and business partners to optimize member benefits, ensure appropriate care delivery, and promote the effective use of healthcare resources. This role performs medical necessity reviews across a wide range of services while ensuring compliance with medical policy, regulatory requirements, and organizational standards.

What You Will Do

• Perform inpatient and outpatient utilization management reviews to determine medical necessity and appropriateness of care settings in accordance with established policies and compliance guidelines
• Apply approved clinical criteria to evaluate and authorize medical services, including:
• Inpatient admissions
• Outpatient services
• Surgical and diagnostic procedures
• Drugs and biologics
• Home health services
• Durable medical equipment (DME)
• Out-of-network services
• Communicate authorization and determination decisions in compliance with regulatory and departmental requirements
• Collaborate with Medical Directors on cases that do not meet established criteria or require additional clinical review
• Ensure adherence to regulatory, contractual, and departmental turnaround time (TAT) requirements
• Meet or exceed daily productivity goals, service levels, and quality standards
• Support utilization management operations and assist cross-functional UM teams as needed
• Participate in staff meetings, trainings, and collaborative sessions to support continuous improvement
• Maintain current licensure and complete all required compliance and professional development training
• Contribute to operational objectives and financial goals through efficient and effective review practices
• Perform additional duties as assigned
  

What You Bring

• Current, unrestricted Registered Nurse (RN) license (multi-state license preferred)
• Bachelor’s degree in Nursing or a healthcare-related field (preferred)
• Minimum of 2–3 years of clinical nursing experience
• At least 2 years of experience in a regulated healthcare or insurance environment (preferred)
• Strong customer service orientation with excellent verbal and written communication skills
• Proven organizational, planning, and time management abilities
• Working knowledge of:
• Insurance industry practices
• Medical coding systems (CPT, HCPCS, ICD-10)
• Claims and authorization processes
• Proficiency in Microsoft Office applications, including Outlook, Word, Excel, PowerPoint, and SharePoint
• Ability to work independently while contributing effectively within a team environment
  

What Makes You Stand Out

• Experience with Utilization Management, Care Management, or Prior Authorization reviews.
• Knowledge of Medicare guidelines, HIPAA regulations, and NCQA standard.
• Familiarity with National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and MCG criteria.
• Ability to thrive in a fast-paced, high-volume, results-driven environment.
• Strong clinical judgment with the ability to manage complex cases and competing priorities.
• Professional demeanor with the flexibility to adapt to changing priorities and business needs.
  
  

Additional Details

• This role requires strict adherence to regulatory, compliance, and departmental policies.
• Position may require flexibility in workload and priorities based on business needs.
• Ongoing training and education are required to maintain compliance and professional standards.
  
  

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