RN Utilization Review Management (Payor)

Utilization Management, RN

Assignment– 3 months (potential to convert to permanent)
Remote – Must Work in CST (no exceptions)
RN - Managed Health/Payor Side Experience a MUST

Job Summary

Utilization Management Registered Nurse (Licensed) performs clinical review of prior authorizations, network exceptions, benefit inquiries, and inpatient and outpatient services. This role evaluates the efficiency, appropriateness, and medical necessity of services using evidence-based criteria, clinical and corporate guidelines, policies, mandates, and standards, while promoting quality care and cost-effective outcomes.

Responsibilities

• Work incoming and outbound calls and queues from multiple sources within mandated timeframes.
• Conduct and monitor clinical review cases to determine medical necessity for inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgeries.
• Document all relevant and specific clinical information accurately in required systems.
• Screen, prioritize, and organize determination requests according to applicable mandates and standards.
• Practice nursing within the scope of licensure, adhering to policies, procedures, regulations, accreditation standards, and state regulations.
• Make evidence-based decisions to ensure compliance, appropriate level of care, and patient safety.
• Stay current on medical and surgical procedures, products, healthcare services and drugs, and general trends in healthcare delivery.
• Maintain up-to-date knowledge of internal procedures, policies, and contracts relevant to utilization management.
• Collaborate with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility, and appropriate service levels.
• Promote appropriate care and quality with a focus on cost-effective and cost-containment measures based on clinical evidence.
• Perform other related duties as assigned.

Requirements

• Registered Nurse (RN) license in good standing, active, current, unrestricted, and recognized in the relevant jurisdiction(s) where duties are performed.
• Bachelor’s degree in Nursing preferred.
• Minimum of four (4) years of clinical nursing experience in at least one of the following areas: medical-surgical, surgical, intensive care, or critical care.
• Experience in utilization management and/or medical review preferred.
• Ability to interpret and apply evidence-based criteria, clinical guidelines, and organizational policies.
• Ability to work independently and exercise sound nursing judgment using critical thinking skills.
• Ability to build and maintain collaborative working relationships.
• Ability to interpret complex clinical and administrative documentation.

Summary Qualification

• Licensed Registered Nurse with solid clinical background in acute or critical care settings.
• Demonstrated experience assessing medical necessity and appropriateness of care.
• Proven ability to balance quality of care with cost-effective utilization of services.
• Comfortable working with multiple systems and managing competing priorities.
• Experienced in communicating clinical information clearly to diverse stakeholders.

Skill

• Strong oral and written communication.
• Attention to detail and accuracy in documentation.
• Critical thinking, analytical decision making, and sound judgment.
• Problem sensitivity and ability to identify potential issues proactively.
• Data analysis and interpretation of clinical information.
• Time management, prioritization, and organizational skills.
• Interpersonal relationship management and teamwork.
• Proficiency with Microsoft Word, Outlook, and SharePoint; ability to navigate multiple systems and perform efficient keyboarding.
• Active listening and customer-oriented communication.
• Commitment to continuous learning and staying current with clinical advances.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one’s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one’s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.

Pay: From $31.72 per hour

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Work Location: Remote

Salary : $32