Utilization Review Nurse

About The Role: This is a TPA, offering clinical support to health plans. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member's benefit coverage while working remotely. Experience: RN or LPN with 2-3 years of UR experience in managed care/outpatient (DME, imaging, colonoscopy, labs) Location: Fully remote, can sit anywhere and be licensed in state of residence Hours: 8am-4pm, 9am-5pm or 10am-7pm CST/EST Pay: RN: 90k ($43/hr) LPN: $70k ($33/hr) Start Date: July 14th Duration: 4-6 week contract with possibly to become FTEPrimary Responsibilities • Perform prospective utilization reviews and first level determinations for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures. • Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments. • Collaborates with healthcare partners to ensure timely review of services and care. • Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. • Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate. • Triages and prioritizes cases and other assigned duties to meet required turnaround times. • Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements. • Experience with outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.Essential Qualifications • Current licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment. • Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) • Must be able to work independently. • Adaptive to a high pace and changing environment. • Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review. • Working knowledge of URAC and NCQA. • 2+ years' experience in a UM team within managed care setting. • 3+ years' experience in clinical nurse setting preferred. • TPA Experience preferred.

Created: 2025-09-22