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Home / Utilization Management RN

Utilization Management RN

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This is a remote position.

The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and assessing the medical necessity, appropriateness, and efficiency of healthcare services requested by providers and members. This role supports the health plan’s utilization management functions in alignment with clinical guidelines, plan benefits, regulatory requirements, and accreditation standards.

The UM Nurse ensures the delivery of cost-effective, high-quality care for members through a variety of activities including utilization review of inpatient, outpatient, and ancillary services using standardized clinical criteria such as MCG and InterQual.

Requirements

Candidates must hold an Associate Degree in Nursing and maintain an active, unrestricted Registered Nurse (RN) license in the applicable state or possess a compact license.

A minimum of three years of prior experience in utilization management within a health insurance company is required.

Strong familiarity with MCG, InterQual, or CMS criteria is essential, as is a working knowledge of UM-related regulatory and accreditation standards such as CMS, NCQA, and URAC.

The role requires advanced clinical judgment, critical thinking, and communication skills, along with proficiency in electronic medical records and utilization management systems.

Preferred qualifications include a Bachelor’s Degree in Nursing and 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 is desirable, along with previous involvement in appeals, grievances, concurrent review, or behavioral health utilization management.

A multistate compact RN license is also preferred.

Benefits

Contract Work

Originally posted on Himalayas

To apply for this job please visit himalayas.app.

Working in United States

The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic consisting of 50 states and a federal capital district, Washington, D.C. The 48 contiguous states border Canada to the north and Mexico to the south, with the semi-exclave of Alaska in the northwest and the archipelago of Hawaii in the Pacific Ocean. The United States also asserts sovereignty over five major island territories and various uninhabited islands in Oceania and the Caribbean. It is a megadiverse country, with the world's th

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