Utilization Management Nurse

Job Description

We are seeking a dedicated Utilization Management Nurse to provide members and healthcare providers with timely prior approval for services, procedures, and out-of-network referrals. This role requires obtaining necessary medical information to make clinical determinations based on appropriate medical policy or criteria, and completing post-service reviews for medical necessity and investigational purposes.

Responsibilities

• Provide precertification and continued stay reviews for members in various healthcare facilities or home health care admissions.
• Assist facilities to ensure timely discharge plans and make referrals to Case Management for ongoing needs.
• Collaborate with healthcare provider staff to gather medical information and facilitate discharge planning.
• Influence and negotiate with providers to resolve utilization review issues and explore alternative treatment options.
• Process utilization management requests using clinical knowledge to interpret medical policy, criteria, and benefit information.
• Interact with Medical Directors and Physician Reviewers for services not meeting medical criteria.
• Collaborate with interdisciplinary care teams to provide optimal service and coordinate member care.
• Accurately document review processes and decisions within the documentation system.
• Meet quality assurance and production metrics established for the utilization management unit.
• Communicate approval and denial decisions to members and providers following regulatory standards.

Essential Skills

• Registered Nurse or Licensed Practical Nurse license in Iowa or state of residence.
• 4 years of diverse clinical experience, including critical care, acute care, and outpatient settings.
• Analytic and critical thinking skills with the ability to make independent decisions.
• Strong verbal and written communication skills, influencing action and facilitating conversations.
• Technical proficiency in Microsoft Office and clinical documentation platforms.
• Knowledge of diagnosis and procedure coding systems (ICD-10, HCPCS, CPT).

Work Environment

This is a 100% remote role requiring a compact license if residing outside Iowa or South Dakota. Working hours are 8 AM - 5 PM CST. Utilization Management Nurses work as part of a multidisciplinary team, continuously seeking ways to improve processes and maximize health resources for our members.

Pay and Benefits

The pay range for this position is $33.00 - $40.00/hr.

Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on May 20, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.

Salary : $33 - $40