Utilization Review Nurse RN - Remote | WFH

Role Summary

The Utilization Review RN Case Manager will collaborate to ensure quality care and cost-effective outcomes that enhance the physical, psychosocial, and vocational health of plan participants. This role operates in compliance with industry standards and regulations.

Daily Responsibilities

As the Utilization Review RN Case Manager, you will oversee all aspects of the utilization review process under the direction of the Utilization Review Supervisor. Responsibilities include inpatient and outpatient reviews, admission and discharge planning, retrospective and readmission reviews, and large case management. You will identify potential large claims, develop quality improvement programs, and maintain communication with medical and payer stakeholders. Adherence to URAC requirements and documentation standards is essential. Additionally, you will provide customer service support and ensure timely communication with internal and external parties.

Qualifications

Registered Nurse with at least 5 years of clinical nursing experience

Bachelor's Degree and/or Certification in UR, Case Management, or related field (preferred)

Strong written and oral communication skills

Positive, proactive team-oriented attitude

Proficiency in computer skills

Active, unrestricted RN license valid in the United States

Other Requirements

Completion of LHCM Orientation and Training Course

Familiarity with URAC UM Standards and clinical review guidelines

Ability to supervise non-clinical administrative staff as needed

Proficiency in using telephones, servers, and other software provided by the organization

Additional Information

This job operates Monday to Friday from 9am to 6pm EST with occasional late shifts and on-call duties.

Remote work-from-home position with required occasional in-person training in downtown Nashville.

Oncology Experience Preferred.

Equal Opportunity Employer statement applies.

Employment Type: Full-Time