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• Location: Little Rock , Arkansas
• Type: Contract To Hire
• Job #11628
• Salary: $31

Utilization Management Nurse (RN)

Location: Remote or Hybrid (United States)
Job Type: Full-Time

Overview

We are seeking an experienced Utilization Management Nurse (RN) to join a healthcare organization focused on delivering high-quality, cost-effective care. In this role, you will perform clinical reviews for inpatient and outpatient services, ensuring appropriate levels of care and medical necessity through evidence-based guidelines and regulatory standards.

The Utilization Management Nurse works collaboratively with providers and internal teams to support quality outcomes, member safety, and responsible utilization of healthcare services.

Key Responsibilities

• Perform clinical review of prior authorizations, benefit inquiries, network exceptions, and inpatient/outpatient medical and surgical services.

• Assess appropriateness of care and medical necessity using evidence-based criteria, clinical guidelines, and organizational policies.

• Collaborate with healthcare providers and internal stakeholders to promote quality, accessibility, and cost-effective care delivery.

• Conduct and document comprehensive case reviews for services including diagnostics, procedures, surgeries, and out-of-network requests.

• Screen, organize, and prioritize determination requests according to regulatory mandates and timelines.

• Ensure compliance with URAC standards, state regulations, and nursing scope of practice.

• Support care coordination and cost containment initiatives while maintaining member-focused clinical judgment.

• Remain current on medical procedures, healthcare delivery trends, and organizational standards.

• Manage inbound/outbound calls and work queues efficiently within required turnaround times.

• Perform additional duties as assigned.

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in good standing (state of practice required).

• Minimum 4 years of clinical nursing experience in one or more of the following settings:

  • Medical-Surgical

  • Surgical Services

  • Intensive Care Unit (ICU)

  • Critical Care

• Strong critical thinking and sound clinical judgment skills.

• Excellent verbal and written communication abilities.

• Detail-oriented with strong documentation and interpretation skills.

• Proficient in Microsoft Office (Word, Excel, Outlook) and comfortable navigating multiple systems.

• Ability to work independently while building collaborative relationships across teams.