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Care Review Clinician
Posted: 03/13/2025
2025-03-13
2025-04-16
Industry: Healthcare - RNs & Nurse Management
Job Number: 40257-1
Job Description
Job Posting: Remote Utilization Management Nurse (LPN/RN) – Healthcare Client
Pay Rate: $42.01 per hour
Work Location: 100 percent remote (Must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside Greater NYC), OH, TX, UT, WA (outside Greater Seattle), WI)
Schedule: 8 AM – 6 PM EST or CST, 40 hours per week, weekend rotation required
Job Summary
Our client is seeking an experienced Utilization Management (UM) Nurse to support inpatient medical necessity reviews, prior authorizations, and other utilization management activities. This role is responsible for ensuring members receive appropriate, cost-effective care in compliance with state and federal regulations.
Key Responsibilities
Pay Rate: $42.01 per hour
Work Location: 100 percent remote (Must reside in one of the following states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside Greater NYC), OH, TX, UT, WA (outside Greater Seattle), WI)
Schedule: 8 AM – 6 PM EST or CST, 40 hours per week, weekend rotation required
Job Summary
Our client is seeking an experienced Utilization Management (UM) Nurse to support inpatient medical necessity reviews, prior authorizations, and other utilization management activities. This role is responsible for ensuring members receive appropriate, cost-effective care in compliance with state and federal regulations.
Key Responsibilities
- Conduct prior authorization and concurrent utilization reviews
- Process 15 to 20 authorization requests per day while ensuring compliance with Medicaid and MLTC guidelines
- Evaluate medical necessity using state policies and MCG criteria
- Identify appropriate benefits, eligibility, and expected length of stay for requested treatments
- Refer appropriate cases to Medical Directors
- Collaborate with multidisciplinary teams to enhance care coordination
- Ensure all documentation adheres to HIPAA and regulatory guidelines
- Meet required turnaround times for standard and urgent requests
- Participate in team meetings and contribute to continuous process improvement
Job Requirements
Required Qualifications
- Active, unrestricted LPN or RN license in one of the listed states
- At least one year of Utilization Management (UM) experience in a healthcare plan setting
- Ability to complete 15 to 20 prior authorization reviews per day in a fast-paced environment
- Familiarity with MCG guidelines for medical necessity determinations (preferred)
- Experience using QNXT/UMK2/PEGA systems (preferred)
- Strong problem-solving, time management, and organizational skills
- Ability to work independently in a remote setting while meeting productivity goals
Additional Details
- Must be able to work between 8 AM and 6 PM EST or CST
- 40-hour workweek with weekend rotation required
- Reliable attendance is critical, especially in the first 90 days
- Candidates must disclose any planned vacations between April and June during the interview process
This is an excellent opportunity for a Utilization Management Nurse to contribute to a team focused on ensuring members receive the right care at the right time. Apply today to join our client’s remote UM team.
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