We’re hiring a Utilization Management (UM) Nurse!
Are you an experienced RN with strong clinical judgment and a passion for supporting quality, cost-effective care? Join our team in a remote role reviewing healthcare services for medical necessity, appropriateness, and efficiency.
In this role, you’ll:
Conduct prior authorization, concurrent, retrospective, and claims reviews using established clinical criteria.
Collaborate with providers, physician reviewers, and care teams to support care coordination and discharge planning.
Prepare clear clinical documentation and timely member and provider communications.
Support appeals, audits, quality improvement, and regulatory compliance.
What you’ll bring
Associate degree in Nursing and an active, unrestricted RN license in the applicable state or a compact license.
At least 3 years of utilization management experience with a health insurance company.
Strong knowledge of MCG, InterQual, and/or CMS criteria.
Working knowledge of CMS, NCQA, and URAC standards.
Excellent communication, organization, and critical-thinking skills.
Preferred qualifications include a BSN, CCM or utilization review certification, a multistate compact RN license, and experience with TruCare, GuidingCare, Jiva, appeals, or behavioral health UM.
Remote | Periodic travel under 10%
Requires a secure home office, mobile phone, computer, internet speeds of at least 100 Mbps download and 10–20 Mbps upload, and typing proficiency of 30 WPM.