Utilization Review Nurse

Utilization Review RN

Location: Remote within IL, TX, TN, NM, OK

Contract Duration: 6 Months -- Contract to Hire

Work Hours: Monday to Friday | 8:00 AM -- 5:00 PM

Job Summary:

Registered Nurse responsible for Utilization Management activities, including reviewing inpatient and outpatient services for medical necessity, ensuring compliance with policies, and optimizing member benefits. Collaborates with providers and internal teams to support effective care and resource use.

Key Responsibilities:

• Review and authorize medical services using established criteria
• Ensure compliance with medical policies, eligibility, and regulatory guidelines
• Communicate decisions and coordinate with Medical Directors as needed
• Meet productivity, quality, and turnaround time standards
• Participate in trainings, meetings, and team support activities

Qualifications:

• Active, unrestricted RN license (multi-state preferred)
• 2--3 years clinical experience; UM experience preferred
• Knowledge of Medicare, HIPAA, NCQA, and medical necessity criteria (MCG a plus)
• Strong communication, organizational, and time management skills
• Familiarity with CPT/ICD-10 and claims process preferred