Utilization Management RN
$100,000–$100,000 year
RemoteUnited States
Job Summary
Conduct clinical reviews and assess the medical necessity, appropriateness, and efficiency of healthcare services requested by providers and members. Perform utilization reviews of inpatient, outpatient, and ancillary services using standardized clinical criteria such as MCG and InterQual to ensure cost-effective, high-quality care. Apply advanced clinical judgment and critical thinking while adhering to clinical guidelines, plan benefits, regulatory requirements, and accreditation standards. Maintain proficiency in electronic medical records and utilization management systems, with experience using platforms like TruCare, GuidingCare, or Jiva. Requires an active RN license, three years of utilization management experience, and familiarity with CMS, NCQA, and URAC standards. This remote contract role supports the health plan's utilization management functions in alignment with clinical guidelines.
Required Qualifications
- Associate Degree in Nursing
- active, unrestricted Registered Nurse (RN) license in the applicable state or possess a compact license
- minimum of three years of prior experience in utilization management within a health insurance company
- Strong familiarity with MCG, InterQual, or CMS criteria
- working knowledge of UM-related regulatory and accreditation standards such as CMS, NCQA, and URAC
- advanced clinical judgment
- critical thinking
- communication skills
- proficiency in electronic medical records and utilization management systems
Desired Qualifications
- Bachelor's Degree in Nursing
- professional certification in Case Management or Utilization Review, such as CCM, CPUR, or CPUM
- Experience using UM platforms such as TruCare, GuidingCare, Jiva, or similar systems
- previous involvement in appeals, grievances, concurrent review, or behavioral health utilization management
- A multistate compact RN license
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.