Job Title: Utilization Management Nurse – Behavioral Health Focus (Remote)
Location Requirements:
Candidates must be located in one of the following preferred states: Arizona (AZ), Florida (FL), Georgia (GA), Idaho (ID), Iowa (IA), Kentucky (KY), Michigan (MI), Nebraska (NE), New Mexico (NM), New York (NY – outside greater NYC), Ohio (OH), Texas (TX), Utah (UT), Washington (WA – outside greater Seattle), or Wisconsin (WI).
Time Zone Preference:
Eastern Time Zone is preferred, but not required.
Work Schedule:
Tuesday through Saturday, 8:00 AM – 5:00 PM EST
Compensation:
$40 per hour
Position Type:
Temporary to Permanent
Position Summary:
A Managed Care Organization is seeking a Utilization Management Nurse to review provider-submitted service authorization requests and evaluate medical necessity, with a primary focus on behavioral health services. This position plays a key role in ensuring members receive appropriate and timely care by performing prior authorizations and concurrent reviews.
Day-to-Day Responsibilities:
Review provider submissions for prior service authorizations, particularly in behavioral health
Evaluate requests for medical necessity and appropriate service levels
Provide concurrent review and prior authorization according to internal policies
Identify appropriate benefits and determine eligibility and expected length of stay
Collaborate with internal departments, including Behavioral Health and Long Term Care, to ensure continuity of care
Refer cases to medical directors as needed
Maintain productivity and quality standards
Participate in staff meetings and assist with onboarding of new team members
Foster professional relationships with internal teams and provider partners
Must-Have Requirements:
Background in Behavioral Health services and/or experience with a Managed Care Organization (MCO) in Utilization Management
Licensure Requirements:
Active, unrestricted RN, LPN, LCSW, or LPC license in any U.S. state
Required Education and Experience:
Completion of an accredited Registered Nursing program (or equivalent combination of experience and education)
2 years of clinical experience, preferably in hospital nursing, utilization management, or case management
Knowledge, Skills, and Abilities:
Understanding of state and federal healthcare regulations
Experience with InterQual and NCQA standards
Strong organizational, communication, and problem-solving skills
Proficient in Microsoft Office and electronic documentation systems
Ability to work independently and manage multiple priorities
Professional demeanor and commitment to confidentiality and compliance with HIPAA standards
Team-oriented with the ability to build and maintain positive working relationships
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