UM Clinical Specialist RN-Physical Health (Full-time Remote, NC Based)
$68,227–$86,990 year
Remote · Morrisville, North Carolina, United States
Job Summary
UM Clinical Specialist RN for Physical Health – responsible for independently assessing medical necessity of inpatient/outpatient services and procedures, conducting pre-certification, concurrent and retrospective reviews, and monitoring treatment to ensure alignment with clinical guidelines and contracts. Supports utilization management processes, communicates adverse determinations with due process, collaborates across departments, and participates in continuous improvement and compliance with state standards. Requires NC residence with ability to travel to office for occasional onsite team meetings; full-time remote role with potential hybrid elements.
Required Qualifications
- State-accredited nursing program
- Associate’s Degree in Nursing (ADN) or Bachelor’s degree in Nursing (BSN)
- Active, unrestricted RN license in North Carolina or compact license
- 3-5 years of nursing experience (as applicable by degree)
- Knowledge of physical health conditions and utilization management
- Strong written and oral communication skills
- Ability to perform pre-certification, concurrent, and retrospective reviews
- Familiarity with NCQA and medical policy standards
- Ability to collaborate with multiple departments and stakeholders
- Proficiency with computer software and workflows
- Travel to office for onsite meetings as needed
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